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091.82.04022.7 <br /> =ii ,_ Waste Tire Survey & Inspection Report Inspection Report Number <br /> NoState of California _ _ .. <br /> Cgrated Waste <br /> (New 1nage Survey Form Page 1 I 1 1108419____, <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1-1 Inspection Type (Fill one) <br /> Site Suffix: L� l 31�J lj 16 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -c.�Jry Q Q Q P Q Q <br /> Vel CHP CIWMB Complaint Educational Visit Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> r'I ess �^vm_ I _ <br /> Street <br /> WWW Inspection Date <br /> L_�X�; _ Rya j� LL <br /> city State L!P C:ae Time In Time Out <br /> Business Rep iD C Title ( I - -1I • ®AM 0 AM <br /> �Z1 ` <br /> Q PM <br /> ®PM <br /> Operational Status TIre.Type Business Role Storage Type <br /> Tire Count(Whole/PTE) k+y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ()( ®Active Q Passenger ®Generator Q Outdoor <br /> ---- _ _ - - - - O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> Q Inactive ®Truck <br /> Longitude - Q Planned ®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 LLuynber Y(,(f� I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IIIIENFORGEMENT STATUS _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> olation <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of ViQ Extension <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 Q Q 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 (Requrred for NOV 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 In Compliance - No Violations <br /> Q 1 Q 1Other: § <br /> �J <br /> Comments eQ✓1-i1- '� ` ( _ �-1 <br /> �0ILoLJ a CC4�C e 1V� ��(" C\-,) 1�( <br /> cez K? <br /> Inspection Form Included: Q ?Aq-;3 y-1663 <br /> Comments Included:Q — <br /> Business ep's Signature Phone Number Insp is ure Phone Number <br /> INSTRUCTIONS ON BACK Co ect: correct: E X M' P L E 1 `2 3 62081 <br /> White Co Yellow Copy:Operator Pink Copy:LEA <br />