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E <br /> Waste Tire Su. „ey & Inspection Repor _ Inspection Report Number <br /> �Id State CIWMB California I 1 - 114 3 7 9 2 <br /> grated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> - - <br /> Business Profile Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t � O l ® 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 /> A4 �ho`Q <br /> Physical Address <br /> CR31-d8 At, 6 1l'S n (�.3c4.-L,/ <br /> Inspection Date c2 <br /> Time In Time Out <br /> Business Rep Title 10 AM AM <br /> (�, l O PM l O PM <br /> — lowet <br /> -- U Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> /� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � v <br /> Active *Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer J$Auto Body Q Car Dealer Q Collection Q 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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 Date 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 O ---- -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <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 Q Other: § <br /> Comments 9a.j,n,. _.. ti7 <br /> Inspection Form Included: '-■— <br /> Comments Included: t;n <br /> ess Rep's Signature Phone Number p i ature Phone Number <br /> ----INSTRUCTIONS 0 ----- - - -- - - ---- - _ - 208 <br /> --- <br /> N BACK correct:* Incorrect ` ; E: X . f , 62os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: ® ■ <br />