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Ins ection Re <br /> -E$;. Waste Tire �fty & Inspection Repel p port Number <br /> �� - State of California T 1 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 I l 1127543 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile [Inspection Details <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: 1 5 a "► 3 `� Q Routine 0 Re-inspection 0 Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: (k) f) �(}(� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> —1%1 - <br /> Inspected By Inspector <br /> Physical Ad.. Lo��5�1c.s� <br /> ss <br /> M Cil C(. I ox C�, <br /> � Inspection Date C A q5 ('� �J I <br /> Time In Time Out <br /> Business Rep Title /l � � Q AM ^ ^ o Q AM <br /> j ptl S PM J( V={1 PM <br /> l�V U, %X b t1 i�l\wl rng�. - -- - , <br /> -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I 1 O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active O Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Indoor <br /> O O Inactive 0 Truck <br /> Longitude - O Planned * OTR O End-Use- Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber 1 1 <br /> LQ Service Station Q Hauler - O Agriculture Q Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> Q 1 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 1 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years _. <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q 0 '14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 0 'I Other: § I -- ---- - -- .�__. <br /> Comments -- r`v\ou' r.0p a1 a 1\�1?{�_ n n '7117 (�_ I . e,'I <br /> Inspection Form Included: QI �� <br /> Comments Included: - <br /> -- ess p's n ture Phone NumbeIns�orsaturePhone Number <br /> - -ns� � , -- -- -62081- <br /> INSTRUCTIONS O CKret� f 21 <br /> White ,opy:C B 'fellow Copy:Operator Pink Copy:LSP. <br />