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07312040463 <br /> ■ Waste Tire SurveyIf1SPeCtlO.r1 Report inspection.Report NumberState Or ■ <br /> rn <br /> c1WMBle IN" Survey Form - Page 1 19 - 10 7 3 5 3 1 <br /> clwMe ts�(New oval <br /> California Inlagrried Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } TPID- ' O I Inspection Type (Fill one) <br /> Site suffix: O g ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S. �a-q,.„�„ Q CHP Q CIWMB Q Complaint Q Educational Visit.Q Other <br /> Business-or Facility Name l� Inspected By Inspector <br /> I l D�] <br /> Physical Address TiR A <br /> I Street �rvtws.� <br /> Inspection Date <br /> I�Sit_ C*_4r CA 5 s 2(S <br /> itG y tate � Time In Time Out <br /> Business Rep Title AM AM <br /> m'MOPM m'm O PM <br /> - <br /> � Operational Status Tire Type Business Rote Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that appy) (FII all that apply) <br /> Tire Count(Whole/PTE) r ! I I L <br /> 1 ®Active ®Passenger 40 Generator ®Outdoor <br /> Latitude 00 Closed Q Altered <br /> Q Hauler Q Indoor <br /> [I-f <br /> • Q Inactive ®Truck., <br /> Longitude _ T�. Q I�O Planned Q End-Use Q Container <br /> Q OTR <br /> Business Type (Fill all that apply) <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 1 I <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility. ENFORCEMENT STATUS <br /> V A U INCti A D A I T R QR ME T Q Notice Of ulolatton 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 NOV or EXT) <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 1 Q 1 Other: § <br /> Comments <br /> �._�-r,,.._—r.�.cp�n��.►r��-hscs d�+-ty ��sl�,�.� was—Hs�C°-`� <br /> OA-,OL Cotd�r. 13Y—Q AJ aT< a4 ► <br /> VyO <br /> Inspection Forth Included:Q <br /> Comments Included:Q r 6 2.3 <br /> Busines p nature Phone Number Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BAC Corre t: Incorrect: )CAMP .� E 1 3 62081 <br /> 2 <br /> . W <br /> ie <br /> Copy.C Yellow Copy:Operator Pink Copy.LEA ® ■ <br />