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09A 6104004:5 <br /> - Waste Tire Survey & Inspection Report Inspection Report Number <br /> = — <br /> i�r State of California I <br /> California Integrated Waste Man agement board Survey Form - Page 1 I 1 - 1088458 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - --I--_ - _ ^ Inspection Type (Fill one) <br /> Site Suffix: 3 0 RoutineQ Re-inspection <br /> ection Q Referral Q Observation <br /> LocalI \ If Referral,choose referral type(Fill one) <br /> Identifier: I SAY, J(Xk t.A �•�(/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicarAddress W I I l ?J !]Ul_ <br /> Street Inspection Date <br /> Cii I +ate ZIH Ccr,- Time In ir_ _ Time Out <br /> Busi s Rep TitleI , l p)I �I-�O AM I ?—T O AM <br /> `I GCI Cne� - oZ V V ® PM v O ® PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> y (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> O •Active Q Passenger ®Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> ® New Tire Dealer Q Auto Repair 0 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 /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date I]] / m / ELI <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 EXT) <br /> O ® 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 Compliance - No Violations <br /> Q Q1 Other: <br /> CommentsOY1- 15— � o�I <br /> (.O <br /> L "y Co', Ge r�Cl lyC,.c_1 ' l` -1 5G. <br /> Inspection Form Included: Q 4471�7� <br /> Comments Included: �I �� <br /> sinessRep's S' ature Phone Number Ins a or's ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co rest: Incorrect: f; X AI W P L E 1 2 3 <br /> White Cop' CIW Yellow Copy Operator Pink Copy.LEA <br />