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� gWaste: Tire SudLy & Inspection Report. Ir,sp&<.In� _#r fez Number <br /> U1111- <br /> State <br /> f <br /> CIWIVIB Waste <br /> eManage) Survey Form - Page 1 1 3 - 1 9 7 9 3 9 3 <br /> State of California <br /> California Integrated Waste Management Board <br /> PartA- Survey- _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / o - ( Inspection Type (Fill one) <br /> Site Suffix: D 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��K �� j� C 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A&� 1.¢ <br /> f 1-1_;# <br /> Physical Address 3 c7 - / G / - �43,3-<; A--1 <br /> Inspection Date r �" LO <br /> Time In Time Out <br /> Business Rep �a Title // AM ® AM <br /> ` t+eC D ® QPM / 7 QPM <br /> /� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � i <br /> l ® � 0 Active ® Passenger ® Generator 0 Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude 0 Hauler 18 Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - 0 End-Use 0 Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ® Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT STATUS <br /> Notice Of ViolationExtension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O --- -- - --- ------- ---- <br /> 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 0 Referred/CIWMB Enforcement::' <br /> 0 0 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities _--_-_ <br /> § Y q <br /> 0 0 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § - -- -- - <br /> Comments G�i7se i�` {CRSb-n 1 Q`4tty 4,.,/ r�ssctii `y -�i"� •, <br /> G'r <br /> Inspection Form Included: 0 <br /> Comments Included: Q <br /> l Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co ec Incorrect: X4, jE"XjAjM[PjL1Ej Ill <br /> Whiteop <br /> Copy:CIW Yellow Copy:Operator Pink Copy:LEA - <br />