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" 09210040502 <br /> == Waste Tire Survey & Inspection Report Inspection Report Number <br /> ear <br /> ,, sIta CIWMB i8l(cola 11 <br /> — 108690 3 <br /> grated asteMa age 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 /> TPID- — Inspection Type (Fill one) <br /> Site Suffix: [Tiq o lqTq 5 l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local c(In <br /> V� � If Referral,choose referral type(Fill one) <br /> Identifier: �70 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ) Inspected By Inspector <br /> Physical AddressG ' <br /> L�1_l�o i4-rd.rn bu I� <br /> - <br /> Street <br /> Inspection Date <br /> City State ZIP Code <br /> "— Time In Time Out _ <br /> Business Rep Title —1 Q AM ��� . Q AM <br /> OPM <br /> Pm4icAl 0 PM __j <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) . (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger 0 Generator 40 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — I 0 Planned Q OTR 0 End-Use ® Container <br /> I <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair •Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 L_Ti'�t <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice of 1/iolation Q Extension <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 Bate <br /> 00 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 I <br /> 0 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 Q 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 ®In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments C71 l (\_ OA �1_ �� fir\ <br /> Inspection Form Included: Q <br /> Comments Included:0 <br /> Business Rep's tg ture Phone Number Ins o S' ture Phone Number <br /> INSTRUCTIONS ON BACK Co rect Incorrect: X SIA L P E 11 :2 3 62081 <br /> White Cop .CI Yellow Copy Operator Pink Copy.LEA <br />