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09211040003 <br /> Waste Tire Su 'y. & Orl lrispeCtlRepor, Inspection Report Number <br /> k..& CrWMB <br /> liorgrated asteManag) Survey Form- Page 1 1 1 - 10 7 9 3 State of California <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: I I— I y <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local L�C�w 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 : Q— Inspected B <br /> P Y Inspector <br /> Physical Address <br /> Street Of <br /> Inspection.Date <br /> City State ZIP Code Time In Time Out <br /> Business <br /> /Rep Title 0 AM 40 AM <br /> lz�] <br /> 0 PM EE � J QPM <br /> — -11 -- j Operational Status. Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Passenger ® Generator Q Outdoor <br /> CIPS <br /> Latitude I ( - -I� O Q Closed Q Altered <br /> Q Hauler ® Indoor <br /> (I � Q Inactive Q Truck <br /> LoQ Planned Q OTR <br /> ngitude0 End-Use Q Container T—] . <br /> Ii I <br /> Business Type (Fill all that apply) 111 <br /> 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 Q Other 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 Q Notice Of Violation <br /> Q Q Q Extension <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 <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 <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/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 Compliance - No Violations <br /> Q Q1 Other: § <br /> Comments <br /> brei` <br /> X20 9 <br /> Inspection Form Included: Q '6•�,'O-`�- /�/_ „�lJ�, �/6g 03.3 <br /> Comments Included: Q <br /> Business Rep's nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK C rreet: Incorrect: 62081 <br /> �( � h� P 1 E 1 23 <br /> White Co y:CIW Yellow Copy:Operator Pink Copy LEA <br />