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Waste Tire Sur & Inspection Report nspection Report Number <br /> State B California j 1 - 1086983 <br /> Cgrated Waste <br /> eManage 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- Inspection Type (Fill one) <br /> Site Suffix: C 5 O Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier ' p�,� - — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addres - l c l -Fm ri_2_ <br /> � <br /> � <br /> Inspection Date Ccr�eC'� � .J53.jI I <br /> Time In Time Out <br /> Business Rep Title o rj ® AM ®AM <br /> i - �k� <br /> �n,'' J 0 PM ' o O PM <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f if Active ® Passenger `M Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive @ Truck <br /> Longitude - O End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> _ClNew Tire Dealer Q Auto Repair Q 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 HaulerQ Agriculture Q Shredder ® Other � t�l <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT ATOS <br /> ---- ---- ---- <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 /> I <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / / <br /> 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O I !, <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O l 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q 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 /> O 1 O Other: § - <br /> Comments AM kl< <br /> 1 ��(�L <br /> - - -- , <br /> (7t maA <br /> kk <br /> Inspection Form Included: Q �tl/? /IUGR <br /> Comments Included: Q (� l -yV -- <br /> Business Rep's 411grakture Phone Number Inspector's ignat a Phone Number_ <br /> 62081 <br /> INSTRUCTIONS ON BACK TeX AAP L 1 2 3 <br /> White Copy CIWM Yellow Copy:Operator Pink Copy:LEA <br />