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r. Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> :191 CIWMB California <br /> 8l(New 04104) SurveyForm - Page 1 Il - 1127887 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � 5 �. S S 5 (� - O Inspection Type (Fill one) <br /> Site Suffix: 1 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: SQ(� JO 'LAA n �OV1�1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> fZ*-k� Dnp <br /> Physical Address I IJG� E .b <br /> t <br /> cA Inspection Date a I I <br /> Time In Timee Out <br /> C) <br /> Business Rep Title I O 0 AM <br /> 0 PM 1 1 Q I* PM <br /> V ` <br /> 9 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 /> f Q Active Q Passenger Q Generator Q Outdoor <br /> - -_- O Closed Q Altered Q Nfl Q J� <br /> PS Latitude N�� Hau er'f Indoo <br /> Gr <br /> O Q Inactive Q 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 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 ® Other Fevcn <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 Date m / m / m <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 /> 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 Q Other: § <br /> Comments 'TI SC. INS .G Sa�IfI,i% C.-_uta <br /> rAA__ -- <br /> Inspection Form Included: Qrill <br /> AW <br /> Comments Included: ®ICu'siness Re 's Siglnatule / Phone Number Insp iIS-ignafJr <br /> e Phone Number <br /> � 62081 <br /> INSTRUCTIONS ON BACK <br /> Correct: Incorrect Gf �/! C�7{ t\ hl1 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />