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03227040112 <br /> " Waste Tire Survey & Inspection Report Inspection Report Number . <br /> eee. <br /> t" ��;Ma 181(N.. Survey Form - Page 1 1 I1 1088106 <br /> callfomla Integrated Waste Management Board Y g <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I I I I Inspection Type (Fill one) <br /> Site Suffix: I ` (3 I I I 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalI I If Referral,choose referral type(Fill one) <br /> Identifier: lf J`OA�..a.1 rJ Co✓�✓v � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ✓ <br /> Inspected By Inspector <br /> Physical Addresff ) —( 0 f > Vtt <br /> I /5/5 No FF 1�2 i <br /> Street <br /> Inspection Date <br /> ,�r P a�•/ � Q 53&,� - <br /> Gfy State ;-Ip Code Time In Time Out <br /> Business Rep Title �I 1 r�O AM �� I� AM <br /> I <br /> PM _.-- ---� --=— - 0 PM i <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) _. (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Count(Whole/PTE) <br /> e f I Active Q Passenger 4P Generator Q Outdoor <br /> .O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> r -O Q Inactive 0 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 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 /> 0 Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- ------------------ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m /m / 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 (Required for NOV or EXT) <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 Q Other: §§ <br /> Comments <br /> Inspection Form Included:Q «9� <br /> Comments <br /> e ep's ignature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct. Incorrect:X(�P q I EjjXj AIIMI P l L I E1' 11['2131 62081 <br /> . White Cop ZYellow Copy:Operator Pink Copy LEA <br />