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Waste Tire Su y & InsectioReorRrtumberUU <br /> 87iiea state of California - ■ - <br /> Cgrated 1 Waste. <br /> Survey Form - Page 1. Ll3 - 1 0 7 9 1 9 2 <br /> California Integrated Waste Management Board <br /> Part A Survey1. BLUE OR BLACK INK PEN <br /> Business Profile IV Inspection Details <br /> Site - ? - ® Inspection Type (Fill one) <br /> Site Suffix: l , Routine Re-inspection Q p Q Referral Q Observation <br /> Local175 <br /> T,\i <br /> ,_- If Referral,choose referral type(Fill one) <br /> Identifier: J.C'A CA �,J� ; Q CHP Q.CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name " <br /> Inspected By Inspector. <br /> Physical Address 1 <br /> IJ <br /> Street <br /> Inspection Date j Z / r'1 <br /> r1 j iyj <br /> l C/ <br /> City i State ZIP Code Time In Time Out <br /> Business Rep Title : m/I- O AM Q AM <br /> G�l� v f� � 0P m ' m QPM <br /> �, -- — <br /> llddd Operation1 Status Tire Type Business Role Storage Type <br /> Tire Count,(Whole/PTE) { (Fill one only) (Fill all that apply) (Fillall that apply) (Fill all that apply) <br /> Active O Passenger Generator Outdoor <br /> Closed Q Altered <br /> GPS L titude O Q Cl <br /> m . Q Hauler O Indoor <br /> O Q Inactive ® Truck <br /> Longitude End-Use Q Planned Q OTR Q Container <br /> ----, ..---__ . -- <br /> Business Type (Fill all that apply) �,• <br /> (ZNew Tire Deal2fi Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> <D Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Hauler Q Agriculture Q Shredder Q Other <br /> Part B -inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility...:A `ENFORCEMENT STATUS_ _ <br /> V I 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 <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 <br /> (Required for NOV or EXT) i <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 i 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 Q In Compliance - No Violations <br /> Q Q Other: -- <br /> Comments <br /> J, <br /> —.-^ � .�-yl ('YI J Y1, t T �r <br /> 1 4- <br /> Iection Form Included: —- - - -- -- -- - — - — -I <br /> ns <br /> p Q r <br /> Comments Included: Q. <br /> i Busl ess Rep's Signature Phone Num`ber' Inspector's Signature Phone Number <br /> -f:U — - <br /> - � ',•� 62081. <br /> INSTRUCTIONS O A K I Correct:* incorrect:)—,4) � , � � ,�; ,� � ,� � �� ,� � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />