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1:91_ Waste Tire Survey & Inspection. Report - Inspection Report Number - <br /> ■ State of California <br /> QM/MB,B (New o<,1e, Survey Form -- Page 1 - 1 9 - 1 0 7 3 3 0 9 <br /> California In Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ Inspection Type (Fill one) <br /> Site Suffix: 0 �6 0� p a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: a�, �ika�i�.v► ( � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected By Inspector <br /> F,—Fc7) t <br /> Physical Address <br /> Street <br /> CAIS 3_7 1 Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> — � --I w' t/l -u m O PM 0 PM <br /> -- -" - --— - Operational Status Tire Type .Bus!ness Role Storage Type <br /> (Fill one only) .(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> &Active ®Passenger Generator ®Outdoor <br /> I IO Q Closed Q Altered <br /> GPS Latitude . �_ I I Q Hauler Q Indoor <br /> Q Inactive F�Truck <br /> Longitude I I Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _J-] <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 Date 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 orEXT) <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 Q Other: § <br /> Commentsp IA& Vi., 4Azs I / pus Ire- __ <br /> ✓f <br /> 91✓ bus 77 3 t,ccics �,,,rrf y <br /> �$rbRptom T7 e-. �(� eS _ fi� S �2S. U <br /> T _ a �eeK cZd`�d ot- �i acts Pre f' ' <br /> Inspection Form Included:Q <br /> Comments Included:Q Maw* w r I — [ <br /> Business R s Signature Phone Number I pec is i ature Phone Number <br /> 62081 . <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:7(� A P L 2 3 <br /> ■ 07284040278 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />