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G91.R2CJaQ2� 9 <br /> Waste Tire Sulay & Inspection Repor Inspection Report Number_ <br /> HDO CIWM8181(New 04104) Survey Form - Page 1. ! I 1 - 1108446 <br /> ���•- State of California <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i — -- I Ins Type <br /> StInspection e Suffix: P YP (Fill one) <br /> ® Routine Q Re-inspectioni Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: LC.�� JV� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> IZ��e�sf� —, •� _ r� a <br /> Physical Address <br /> street i 1 <br /> � Inspection Date <br /> 93�73 <br /> C =`0—J Time In I ` Time Out <br /> Cityy St <br /> 1 �.ts 7_if'x. 0'3 _ _ <br /> Business Rep Title —I . O AM h j I : ; i Q AM <br /> �-----' --: . I---I-- ' ® PM i Business Role 1 I ® PM <br /> tc <br /> Operational Status Tire Type u o e Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> D ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> -- 0 Q Inactive ®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 ®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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility KENFORCEMENT STATUS <br /> V N 01 MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 <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 DC>7 <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/C-IWMB 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 C-ompliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> J(1 <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Busines ep' nature Phone Number Ins to ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [EIXIAIMIPILIEI, 12 3 <br /> White Yellow Copy:Operator Pink Copy:LEA <br />