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U8.. e10G0055 <br /> Waste Survey.&. Inspection Report Inspection Report Number <br /> 1tC State CaliforniaSu Survey Form Page 1 i 2 0 1 0 $ 8 2 <br /> CIWMBB 787 tew Y <br /> CaliforniaalifIntegrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � n /Z � � _ � Inspection Type (Fill one) <br /> Site Suffix: I ! I 7 "(7 ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ca T" Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> CityS_ Q/ 5�G l <br /> State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> IT] m 0 PM 11:1 Q PM <br /> ( ) Operational Status Tire Type Business.Role Storage Type <br /> Tire Count Whole/PTE I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ID Active Q Passenger (0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m• ti Hauler � Indoor <br /> p Q Inactive *Truck <br /> Longitude — Q Planned Q OTR • End-Use Q Container <br /> Business Type (Fill all that apply) <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 ® Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture ® Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORC-EMENT STATUS _ <br /> V A !HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Date m / m / LL <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or FJC� <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CtWM6 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 Q Other: § <br /> Comments �o�,.�-r7J>r �NJ�O,C.Grg?.+ e'er �b dam-- ��Cl••,�/�_ tw/a-4r_�y0'�/•- �e <br /> Inspection Form Included: Q 1� p <br /> 209 <br /> Comments Included: Q <br /> Busi e s Sig re Phone Number Inspector's Signature Phone Number <br /> ' � <br /> INSTRUCTIONS ON BACK Core Incorrect: X M P L E 1 2 31 62081 <br /> ■ White Cop CIWMB Yellow Copy:Operator. Pink Copy:LEA ■ <br />