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092.80040920 <br /> r = Waste Tire Survey & Inspection Report Inspection Report Number <br /> - <br /> State <br /> —. 10869°t�- sate of calnornla I 1 3 5 • <br /> Cgrated Waste <br /> Survey Form'- Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t Inspection Type (Fill one) <br /> Site Suffix: 0 Routine a Re-inspection 0 Referral 0 Observation <br /> Local �' 1 If Referral,choose referral type(Fill.one) <br /> Identifier: Sa J O uu_n u 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Lk_� (0 <br /> Physical ddress <br /> Strcet t--� <br /> Inspection Date <br /> L" Q W v Time In Time Out <br /> City tate �Ir t ode _ <br /> Business Rep Title nn ,1— . I ^ 0 i AM h �—I O Q AM <br /> ��� 01.1 I I - �0PM � iO v � PM <br /> - � - -UU- - - - - _ r _ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I ( O (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r ,p <br /> IS Active ®Passenger 0 Generator Out <br /> • O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility BENFORCEMENT STATUS <br /> V M ICAL!lLINGM IN 01 M 9N NI I.Mi REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers.. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements at m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX77 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I C-IWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments <br /> c�a�4 <br /> �1-cG iy uuS V_i bvi <br /> Inspection Form Included: 0 --( <br /> Comments Included: 0 - <br /> Business Reps ignature Phone Number Inspectprs Sigrnahure hone Number <br /> INSTRUCTIONS ON BACK Corr ct: Incorrect: X A JVI P L 1 '2131 62081 <br /> White Copy. IW Yellow Copy.Operator Pink Copy:LEA <br />