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-e1 _ Waste Tire Su*y & Inspection Reporiolnspection Report Number <br /> State of California <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 ! 8 - 1 0 7 9 3 9 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- d _ p I Inspection Type (Fill one) <br /> Site Suffix: ✓ * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspec or, <br /> Physical Address 3 — / /v / S',�/16-0 TV)^kDV4- <br /> Inspection Date � (� � `/�' g � O 9' <br /> c <br /> Time In Time Out <br /> Business Rep l Title AM ® AM <br /> �Pl {�7—�' IYLt� o PM O 0 PM <br /> Operational Status Tire 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 /> ® Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® 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 Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> - -- -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> PRC 42951 -Waste Tire Hauler Registration and Trans ort of Tires Q Notice Of Violation Q Extension <br /> �( A HAULING AND MANIFEST REQUIREMENTS <br /> 0 § 9 P I <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ------------.... <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> O O .1 Other: § <br /> -- <br /> Comments <br /> f� V <br /> Inspection Form Included: G <br /> Comments Included: 401, <br /> Business p's S' re Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK = ����MEJXJAJMJPJLIEI1112 3 62081 <br /> White Copy:CI B Yellow Copy:Operator Pink Copy:LEA <br />