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" c <br /> Waste Tire Suly & Inspection Re�or Inspection Repo,t't humber <br /> no .State of California ■ <br /> Cgrate18aste'Mnage' Survey Form - Page 1 . �' <br /> I1 -(1088365 <br /> ` �,dCalifornia Integrated Waste'Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L r` - Inspection Type (Fill one) ` <br /> Site Suffix: , J <br /> _ Routine Q Re-inspection Q Referral Q Observation <br /> Local y If Referral,choose referral type(Fill one) <br /> Identifier: �(;/ l 0,i(�L: �y� C'[Fl `t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ✓ <br /> ( Inspected By Inspector <br /> -T <br /> Physical Address <br /> J ,.a t (l t .� <br /> / 0 a VV1t,Qj—1 We <br /> Street <br /> ff 1 <br /> Inspection Date / 7 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title t r0 AM 0 Am <br /> t t lJ XD PMtUt !. / ® PM <br /> C,Irc ,I G �.1� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f <br /> M/ 5 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m . Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler' Q Tire Derived Fuel <br /> OUsed Tire Dealer OAuto Body O Car Dealer QCollection <br /> O Crumb Rubber <br /> Q Service Station Q Hauler' Q Agriculture Q.Shredder Q Other <br /> Part B Inspection of.Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS- <br /> V ' A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q .O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§184.59.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 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 /> .0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ;. In Compliance - No Violations <br /> Q O 1 Other: § / ��tt ! <br /> Comments ti t,� `� C �i'C.iti ll�i > Cl /w f :- /!� > �' JL.1 I t T rt rf <br /> "�,:C� v4:`f�..; �f, �� I'r �/✓e `ur fr (' 7t <br /> Inspection Form Included Q' ` <br /> ( ' <br /> Comments Included Q -- g p � 9 Phone N <br /> Business/ep-, Signature N Phone Number lns ector's Signature umber <br /> ,�, 62081 . <br /> INSTRUCTIONS ON BACK Correct:J0 Incorrect: X .; . M I p I L II 3 <br /> ■" WhiteCopy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> i <br />