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l 091.610:.40021; <br /> HIM Waste Tire Survey & Inspection Report Inspection Report Number <br /> Ii State B81(NeCalifornia - Survey Form - Page 1 - Il - 1088499 <br /> Cgrated 1(t eManag4) Y II <br /> Callfomla Integrated Waste Management Board -J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I O i O0 Routine QRe-inspection QReferral QObservation <br /> Local �` t I If Referral,choose referral type(Fill one) <br /> Identifier: �S J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ��� I I 0 ILB <br /> Es <br /> Street -� <br /> - � Ins ection Date <br /> Ci: 51 'e /Ir-,Corr Time In Time Out <br /> Business Rep Title <br /> , —, ^ IAM ' I . I - SAM <br /> lv !0 PM I 11 <br /> 1 I . O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only). (F.ill all that apply) (Fill all that apply)" (Fill all that apply) <br /> ®Active Q Passenger Generator e Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> i <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned i®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 L1 tnOwQr'4 cJ dW <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other I_ S TCQQ� <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEM1ENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of lfiofation 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. C^ompliance 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 EX7) <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 O 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 In Compliance - No Violations <br /> Q 1 Q 1 Otherp `1: § ll _ <br /> Comments _u -m— �lIJ1j <br /> no (.a— <br /> t <br /> �cst•�.� 1.'�•,,�;���_tom��v�v���e.,- - -r_a�_ —one HT1- a_ �l�� o <br /> Inspection Form Included: Q Comments Included: Q - �`` ���-� • �. o . - - (ol <br /> siness Rep' ature Phone Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK rrect• ncorrect: X M P LjEj: 1112E <br /> White C y:CIW Yellow Copy:Operator Pink Copy:LEA <br />