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09098040463 <br /> =LI= Waste Tire Survey & Inspection Report .InspectionReport Number � <br /> ;; sLa l ewomw I 1 - 110 3 7 2 2 <br /> Crimted tlNewBNab) Survey Form - Page 1 i <br /> CallfomA IMegmteC Waste Management Boertl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> { TPID- Inspection Type (Fill one) <br /> Site Suffix: L/L��l (, 6 e 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 By Inspector <br /> I <br /> r � <br /> PhysicsAddressp <br /> awe <br /> I <br /> Sheet /.// � Inspection Date / © D <br /> Tlj�ta — —(-0. SS X30 I / I�21 <br /> Cil ty - a / �t�!s Z:P�JL9 Ime In Time Oust <br /> Business Rep Title i —11VAM I I I ,I I &AM <br /> _Q 9 i D:D O PM D d O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (F)II one only) (Fin all that appy) (Fill all that apply) (Fill all that apply) <br /> . Active Q Passenger 9 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data 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 IR comp-ift"Se Ns <br /> Q Q Other: §/}�— — <br /> Comments <br /> o7 <br /> A—:1. <br /> f <br /> Inspection Form Included:Q <br /> Comments Included:Q �� Z � <br /> Business Rep's Signature Phone Number In act. Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:Is Incorrect:VX 62081 <br /> (� E X A M P'L E 1 2 3 <br /> ■ While Copy.CIWMB Yellow Copy Operator Pink Copy.LFA. <br />