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DWaste Tire Survey & Inspection Report: Inspe on eport- umber <br /> DI . _ — <br /> LIM State B 181(New <br /> I 1 1086916 <br /> Cgrated Waste <br /> nage) Survey Form Page 1 <br /> California Integrated Wasta Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profilee �--- Inspection Details <br /> TIPID- III---lll___ JInspection Type (Fill one) <br /> Site Suffix: <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: LSA� ��r•Q�,�(1i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility lame "' ���t 1 <br /> C < \ Inspected By Inspector <br /> I R - - Vt <br /> Physical ddress ( 0 111 <br /> Street <br /> Inspection Date <br /> CitLy � , <br /> s taTe—ffF Coda Time In Time Out <br /> Business Rep Title [a. : [4 � AM [:EH Q AM . <br /> O PM O ' it 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 /> 1 1 Active • Passenger .Q Generator Q Outdoor <br /> 110 Q Closed ®Altered <br /> GPs Latitude ; i I 0 Hauler Q Indoor <br /> -I — '-- - Q Inactive I6 Truck <br /> I o <br /> Longitude rT I ! I Q End-Use Q Container <br /> Lon <br /> 9 Q Planned ® OTR <br /> Business Type (Fill all that appy) <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 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 NFOR-GEMEN STATUS <br /> V A HAULING ANDMANIFEST REQUIREMENTS ® Notice Of solation 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 1.4 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date a S <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> • Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> • 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 Referred f C-IWM E for ment <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 Q In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments ^x 'ns �n� } _1 - 1,'14 <br /> A LA I on _T ticc § o 0 oi <br /> � r <br /> Inspection ForthIncluded: 5 11p ,3_L-C7 - J �( <br /> Oq <br /> Comments Included: 1 <br /> Business Rep's §4nature ! Phone Number. Insp or's Si Nature Phone Number <br /> INSTRUCTIONS ON BACK Co rest: Incorrect: 62081. <br /> EX � MPL lt3 <br /> White Copy CIWM Yellow Copy.Operator Pink Copy:LEA ® . <br />