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�9i10t���:54 <br /> Waste Tire Survey & Inspection Report Inspection Report Number. <br /> rrCd9: . <br /> �d State of California <br /> CIWMB 181steM nage Survey Form.- Page 1 1 7 1 0 7 9 3 6 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> jBusiness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: U f Ell ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r--� <br /> 1 If Referral,choose referral type(Fill one) <br /> Identifier: -1u�� �( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> L_01n-�'Q_(��\.n111, �ct�ec pt i _�_�C ' F11 <br /> Physical Address <br /> Street � � / h ,■ / _ <br /> 1 f Inspection Date <br /> Y�o�n <br /> State ZIP Code Time In Time Out " <br /> Business Rep Title , AM 0 AM <br /> PM ® ' ® PM <br /> - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE), : �f <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 'f I I f I <br /> ®Active 0 Passenger ®Generator ®� 0 Closed 0 Altered Outdoor <br /> IJGPS Latitude L— . L-1-- —I� 0 Hauler 0 Indoor <br /> — ----1 ---- O 0 Inactive ®Truck <br /> Longitude — III___I Lt <br /> I , (— I — 0 Planned 0 OTR 0 End-Use 0 Container <br /> _���_..JJJ ��11��11 <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler----. 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I I <br /> Part B-.Inspection of Waste Tire Dealer; Generator, Hauler and End-Use Facility ENFORCEMENT S1TATUS <br /> ------------------------------------------ <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of yiotation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orEXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers . 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use.Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 1 0 Other: § <br /> Comments <br /> � I <br /> ce- (Ali- s' <br /> Inspection Form Included: 0 Q <br /> Comments Included: 0 — -- <br /> Business Rep' Si ature Phone Number Insp tor's Signature Phone Number <br /> ---- 62081 <br /> INSTRUCTIONS ON BACK7rr Imeorrect: �. X N4 P :L 1�2 3 <br /> WhiteB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />