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.. Inspection Report Number <br /> vaa�s®���vs <br /> Waste Tire Survey.& Inspection Report <br /> State B California I 1 - 112 7 5 9 <br /> Cgrated 1(tieMana a) Survey Form - Page•1 � � f 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1— i-S L4; a 9 S=j] lo]E- •Routine O Re-inspection O Referral O Observation <br /> Local ' <br /> n \ If Referral,choose referral type(Fill one) <br /> Identifier: ( �� JAL\n O CHP O CIWMB O Complaint O Educational Visit O.Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Strear Pe i o I I <br /> Ins coon Date <br /> City 9-!'ata %1P Code Time In Time Out ___ <br /> Business Rep Title Q AM <br /> TPM , 1 Q AM <br /> i �J �i QPM <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 /> r f I `®Active ®Passenger Generator Outdoor• . <br /> 0 OClosed O Altered <br /> GPS Latitude I I O Hauler O Indoor <br /> 0 O Inactive. ®Truck <br /> Longitude — I I , ; ' I i� O planned O OTR O End-Use O.Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government .O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber \� <br /> V , <br /> O Service Station O Hauler O Agriculture O Shredder. ®Other L <br /> Part B-Inspection of Waste Tire Dealer,-Generator;Hauler and End-Use-Facility :ENFORCEMEN"�T�,rSTATUS& r <br /> `HAULING ANDaMANIFEST REQUIREMENTS.. <br /> O Notice Of Violation ,Q Extension. <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ._ * ;" <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance)Deadline.. '' ' <br /> O O PRC§42956-Registration/Decal in Vehicle w <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Da 'e # S <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Reg6ked for NOV or EXIT) $ <br /> ••^.'�. a^s.. >F•�t�Fi'W51:91 Rat$t vm. .T.*&- �,iCrs <br /> iO O 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 O Referred!,CIWMB: Enforcement <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities FIV <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance -,No Violations <br /> O O Other: § <br /> Comments <br /> (�-0 V Q1a tioSl <br /> - q- 1 1 L <br /> "vis T�`Oiink eft-. Gl �0.�l.Ultr- <br /> Inspection Form :nc <br /> ncluded: O q v <br /> Comments luded: Q — —Ot (i�nsp�_ <br /> - — ---Busi ss a Sig ature Phone Number or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Cor ect Incorrect: , .(yl qj IX A hh P L 1112 3 62081 <br /> White Copy CIW Yellow Copy:Operator Pink Copy:LEA ® ■ <br />