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_ Q9� 8204.0215 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B California I 1 - 1108459� <br /> Cgrated Waste <br /> Survey Form - Page 1 <br /> California Integrated Wasta Management Board I I <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Ll 1,5 lalaLqjo_[��] <br /> 0 i ® Routine . Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �(��/y� Inspected By Inspector <br /> Phys�a� Arrests �- I - ! l 4 <br /> StreetI <br /> Inspection Date 1—I i11 <br /> City ate ZIP Code Time In v Time Out <br /> Business Rep Title I I� : 1 Q AM /-i - I� AM . <br /> --I- - ® PM G - ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that appy) <br /> O ®Active Q Passenger 4) Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Other I t <br /> Part B: Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> MjM HAULING AND MANIFEST REQUIREMENTS Q Notice Of la inn Q xtension <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 t)eadline <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 ( equied for NOV or <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!GIWMB 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 Q Other: § <br /> _J <br /> Comments O _L,,_� ����CM ` � <br /> t���� 1�.� t1CJ <br /> of <br /> Inspection Form Included: Q l'L <br /> Comments Included:Q P - <br /> Hess Rep' Wgtr. Phone Number Inspe t rs Si toe Phone Number <br /> C rrec : ncorrect: 62081 <br /> INSTRUCTIONS ON BACK <br /> EXAMPLE: 123 <br /> White Co y:CIW Yellow Copy.Operator Pink Copy:LEA ■ <br />