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09161040027 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ofCalifornia(New y g 1088472Cgrated ast eManag) Surve Form - Pa e 1L_11 _j <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` r i Inspection Type (Fill one) <br /> Site Suffix: I i la Ii O 51 f�J - L�j)__[ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,goose referral type(Fill one) <br /> Identifier: I Sats �oo�U�n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _1_�J& <br /> Physical Address <br /> Street <br /> Inspection Date +5 / =) j / 1019 <br /> -on A'_%)z <br /> .ii; orato /.lr=CUTQ Time In_ _ Time__Out <br /> Business Rep Title I -r I I AM I L I O I Q AM <br /> OPM <br /> 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> t t ®Active Q Passenger 0 Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> _ 0 Q Inactive I*Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadlin <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements to / <br /> Q O 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 R Quired for NOV or DCn <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 Referred/CtWMB 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 - o Violations <br /> Q Q Other. <br /> Comments �2.. �►n5 �— tX�,0�1-- �� 4r�1(11-- �a�`a��P-4 W4.S <br /> J <br /> 16"k <br /> Inspection Form �nc <br /> ncluded: Q <br /> Comments luded: ?L v � � <br /> sines.Rep's Signature Phone Number &Insp ors Signature Phone Number <br /> INSTRUCTIONS ON BACK Co ect: In rrect: f; XAh A P LIEI 111213 62081 <br /> White Co .CIWM Yellow Copy.Operator Pink Copy.LEA <br />