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088800100 <br /> vrc <br /> Waste Tire Survey & Inspection Report Inspection eport um er ■ <br /> r; <br /> Stateof81(Nmla Survey Form - Page 1 1 3 - 1 0 7 9 4 9 8 <br /> CIWMB 191(New nage <br /> 4104) <br /> Califomfa Integrated Waste Management Board <br /> Part A-SurveV BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- [ITInspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S c� -amu$„�. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J <br /> FITo LA-h,, <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> LE 0 P m ' 0 P <br /> - -- -- — — — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE).. (Fill one only) (Fin all that appy) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> I I IO Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> ®Inactive Q Truck <br /> O <br /> Longitude - I I .I I I I�I Q Planned Q 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use.Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 Date <br /> M / m / m <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 EXT) <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 I 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments: �/n <br /> A- <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number spector's Signature Phone Number <br /> � <br /> . INSTRUCTIONS ON BACK Correct: Incorrect:X(� -,�J( Ah E X a P 'L 62081 <br /> 1 'Z 3 ® ■ <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />