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os�s6agags3 <br /> =i Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> KState <br /> ee.I - of California I 1 - 1108496 <br /> Cgrated 1st eManagei 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: 1 ` 1 let 1 _3 0 g - O l J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> - �� <br /> Physical Address 0 <br /> rn <br /> Sheet <br /> C� Inspection Date <br /> t �-1�_1. 0� Siateqo Time In v Time Out <br /> Business Rep Title (�j 0 AM T� �T Q AM <br /> 1 c+ a -7 I 0 PM I _ Id_I I ` I. O PM <br /> `Sc 1tc.� 2✓v„�,,,._______;t J�Jc_-_ Hna P ! Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) - (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' v (D Active Q Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude _ _ Q Inactive ®Truck Q Hauler Q Indoor <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 ®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_- __ I <br /> Part B- Inspection of Waste Tire.Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <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 Deadline <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 .(Required for NOV or FXT) <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 1 Other: § <br /> Comments 0L+' _1() <br /> L <br /> Ilk <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Tnsp ors ig t Phone Number <br /> —1 <br /> INSTRUCTIONS ON BACK Co eet: In, meet: X jdt P 'L E1 1112N 62081 <br /> White C Yellow Copy:Operator Pink Copy:LEA <br />