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■ Waste Tire Su&y & Inspection Report Inspection Report Number <br /> GiGd9 State of California <br /> _. --- <br /> CIWMB 181eanage Survey Form - Page 1 I 1 - 1088162 <br /> California Integrated WasttM <br /> Waste Management Board <br /> Part A Survey BLU_ E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> + Site Suffix: L r ' r 1J_ J� I I <br /> T _– ��� QRoutine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier. ,..j J vn - ,�.�.�� --, � <br /> Q CHP <br /> Q CIWMB <br /> Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> --- <br /> T. <br /> _ __ _._ ,> _ _ <br /> Physical Address __—� �-. <br /> C <br /> L // G AVS <br /> Street — -- <br /> Inspection Date <br /> State Z* Code-J Time In Time Out <br /> Business Rep <br /> Title � �0 AM O AM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Cunt(Whole/PTE) !,i(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> a <br /> Active Q Passenger Q Generator Q Outdoor <br /> o <br /> Latitude Q Closed Q Altered <br /> GPS Q Q <br /> Indoor <br /> _ <br /> -- -,0 Q Inactive Q Truck Hauler <br /> Longitude � <br /> • Q Planned Q OTR Q End-Use Q Container <br /> Business Type,(Fill'ail, <br /> QNew Tire Dealer Q Auto Repair ® Trucking Fleet Government QRetreader QDismantler <br /> 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 <br /> A Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V -- - -- --- - - <br /> _ _ - I <br /> Part a !HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q 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 m m I 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 <br /> Q Q Other: § Q In Compliance - No Violations <br /> Comments p <br /> a <br /> Inspection Form Included. 0 <br /> l y <br /> Comments Included. 0, - - -- _ <br /> ,Business Rep's Signature Phone Numberlarospector°s Signature phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: / A,00111 1- �� q L 3� <br /> 62081 <br /> eWhite Copy:CIWMB Yeflbw Copy:Operator Pink Copy:LEA <br />