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09I.61040-047- <br /> Al Waste Mire Survey & Inspection Report Inspection Report Number <br /> State , <br /> II CIWMB <br /> 181(New Survey Form - Page 1 I 1 - 1088488 i <br /> cIWMe,e,,r+ewaaoa)� y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f i Inspection Type (Fill one) <br /> Site Suffix: I ` - O Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: lcaA �� C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 <br /> /7� <br /> Physical Address L 9 - ! c) l Lge0 CSCA <br /> ____j <br /> Street_ O Inspection Date I I <br /> - �� — �'- �� Time In Time Out _ <br /> 5� <br /> iy State 7_f. �crre <br /> Business Rep Title <br /> !vn —I 1V AM O AM p` 5 �/ ia 1 ►1cPM <br /> 41 PM <br /> j'JN <br /> Operational Status The 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 /> I*Active I* Passenger •Generator IV Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - <br /> - 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 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 40 Other J"Oft <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST JR.EQUIREMENTS <br /> 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 <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 OV or HXT) <br /> Q Q 14 CCR§16459.3-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 C-ompliance - No Violations <br /> 101 Q 1 Other: § <br /> Comments 1 I 1 <br /> �v 0471 <br /> 01 McAc 01-o-aua, <br /> I <br /> spection Form Included: Q <br /> Comments Included: dt(J f1 <br /> •- usine e s i re Phone Number Ins tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C feet. Incorrect: �X A M P L 1 2 3 <br /> ■ White py.CIW Yellow Copy.Operator Pink Copy LEA <br />