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i <br /> •tE1 <br /> Waste Tire Survey & Inspection .Report- Inspection Report Number <br /> °°� .-State of Ca6forn;a Fil — 108841 7 <br /> Cgrated asteManage Survey Form - Page 1 <br /> California Integrated Waste Management Board y <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ,3 -1 �11119 1 3 - O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identifier: JoC ��'1 t/)1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � ) (((((( Inspected By Inspector <br /> ��e. rn ons- ►mss I <br /> Physical ddress <br /> Street <br /> Inspection DateEE <br /> City State ZIP Code Time In Time Out <br /> Business RePl Title 0 AM 0 AM <br /> ®PM I l ' !✓ ;"� ; ® PM <br /> - -- — -- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude 10 • Closed Q Altered <br /> CIPS Q Hauler Q Indoor <br /> . --'— --'---i Q Inactive Q Truck <br /> - -:—T-:_ - -- -=-i- --0 <br /> Longitude - 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 ® Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility BENFORCEMENT STATUS <br /> V A ;HAULING )]MAN IFEST 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 m , m / m <br /> Q O <br /> 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 iVOV or DC7) <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/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 <br /> In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments `C. <br /> \ <br /> 4T:j C*1L tss—tel os�� <br /> nr•, C6 4 civ c,� �1c� �J�f c o dyj e�� a,� st c 1e: t <br /> Inspection Form Included: Q G <br /> Comments Included: Q � �'� t� �� <br /> Business Rep's.Xgnktqre Phone Number Inspe to .s Sign ure Phone Number <br /> — 62081 <br /> INSTRUCTIONS ON BACK Co rest: ncorrect: X A P �, 1 ;'Z 3 <br /> White Cop :CIWM Yellow Copy:Operator Pink Copy:LEA <br />