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0 09203050037 <br /> ;giilj Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> iaa State of California <br /> California Integrated WasteeManagement Board Survey Form - Pagel. � I 1 - 108691 <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 5 3 . lJ 1 e Routine Q Re-inspection Q Referral Q Observation <br /> Local1A?n If Referral,choose referral type(Fill one) <br /> Identifier: n J Q(1 -1 Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility,Mame 1 ` Inspected By Inspector <br /> u 0Wcs� <br /> i _Physical Address A—M <br /> L—a�20�IV.o_�:1��. I <br /> Street <br /> Q Inspection Date FO <br /> �1 <br /> Citq �O tate Zlp Code Time In Time Out <br /> Business Rep Title � O AM l i� I� O AM <br /> ELZ711 � <br /> 0' ;' PM19-PM <br /> -- u Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i®Active Q Passenger 46 Generator Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude. -�- Q Hauler Q Indoor <br /> - - - - Q Inactive Q Truck <br /> - - — - O <br /> Longitude Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B -Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility 1ENFORCEMENT STATUS <br /> WMIRYMAIINMANDIMAMIFEST REQUIREMENTS Q Notice Of violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXTJ <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred t CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators to Compliance - No 1/iolations <br /> Q Q 1 Other: § <br /> Comments _ tl - �n--1` f/� —�, � WAS _ <br /> Inspection Form Included: Q <br /> - Comments Included: <br /> Business Rep's §ignature P one Number Inspe ors I ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co reet ncorrect: t:. P L 1 3 <br /> ■ White Cop CIW B Yellow Copy.Operator Pink Copy:LEA ® ■ <br />