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■ Waste TirAu ey & Inspection ReqWo Inspection Report Number ■ <br /> NO,;M State CIWMB California I 1 - 10 8 8 4 7 9 <br /> grated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Tplp- { Inspection Type (Fill one) <br /> Site Suffix: t)' j _�_i - Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t tiw 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address a, "!] 11J__cIA <br /> Street <br /> r Inspection Date <br /> Cit v State ZIP Code Time In Time Out _ <br /> Business Rep Title ..,O PM 1.._ L_ PM <br /> Operational Status Tire Type Busi sen s Role Storage Type <br /> ( y) ( ppy) ( apply) ( apply) <br /> C I Fill one onl Fill all Yhat a I Fill all that a I Fill all that a I <br /> Tire Count (Whole/PTE) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> - O.. 0 Closed 0 Altered <br /> GPS Latitude $ ( I0 Hauler 0 Indoor <br /> L-.- --I —L— ___ -- 0 Inactive 0 Truck <br /> Longitude - - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> I) 0 14 CCR§18459.3 Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> I <br /> Inspection Form Included: 0 { <br /> Comments Included: �L.rr <br /> Business Rep's Signature Phone Number Inspector's Signatufte -- } Phone Number <br /> X I _�(�T_�1j 19 3 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: � ;�,r�, � �' � f � � :� <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />