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09210040508 <br /> Waste Tire Survey & Inspection. Report Inspection Report Number <br /> trc. <br /> is - State of California <br /> Lo T 1 <br /> California Int gra edfWas eeManagement Board Survey Form - Page 1 + + 1108493 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site SuLD -inspection ectionTPID- fII � I Q Referral Q Observation <br /> Local \ / If Referral,choose referral type(Fill one) <br /> bil Identifier: � 1 ) ( /� — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business o1;Facility Name (1() f( Inspected By Inspector <br /> Physical�Address <br /> ^� ►+.�!v, <br /> Street 0=6 <br /> —I C 4� 0(\ CA ��� Inspection Date <br /> City Sian ZIP Code, Time In Time Out <br /> Business Rep Title AM <br /> I ( �— O AM <br /> JL. .. tC�2.. 1 t_t_ _ ,ler- �_�O PM ----'--� t----'O ® PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) q (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> 1 ®Active Q Passenger Generator J@ Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude O Hauler ® Indoor <br /> O Q Inactive 46 Truck <br /> Longitude - Planned Q OTR O End-Use ® Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> I 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 Notice Of Violation Q Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers, Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / ID <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB E] <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q I O Other: § <br /> Comments w1� �� �W-►_ O� 1 J— Q-G►�� Dub Wv��-1 ' W r <br /> S <br /> 3_rj _V_WaS e_��, _Wa_ - <br /> Inspection Form Included: Q <br /> Comments Included: o <br /> ;Rep's Signature Phone Number Inspe is Signature - Phone Number <br /> INSTRUCTIONS ON BACK Cor ect: Incorrect: ( 62081 <br /> EXa �gPLE 1 '23 <br /> White Cop :CI Yellow Copy:Operator Pink Copy.LEA <br />