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�921Jt34Q235 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> eao_ <br /> Hir - State of Californla <br /> r Cgrated 81 stfeManag) Survey Form - Page 1 I 1 - 108847. 1 Ca <br /> l <br /> i <br /> f <br /> o <br /> r <br /> n <br /> i <br /> a <br /> 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: ' S e Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: is 1 ��n Wl�( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I v5oStr <br /> Sit)A&I <br /> Inspection Date(�'�►`State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> _�' ' l I ®PM y� ' y I�I PM <br /> (�unu car -- = - <br /> -- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all:that apply)V) (Fill all that aPPIv) (Fill all that apply)Count(Whole/PTE) . <br /> ®Active ® Passenger ®Generator Outdoor <br /> o 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - ,i I 0 Planned 0 OTR 0 End-Use 0 Container <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 /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other I 1 <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFESTI REQUIREMENTS <br /> iolation <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of V0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m [11 <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 <br /> 0 0 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/C-IWMB Enforceme t <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators W In Compliance o Violations <br /> 0 1 0 Other: § <br /> CommentsVp <br /> � t <br /> e. `� yg o r u (1r'U b W_ IT9 __al�� <br /> Inspection Form Included: 0 �`/ Q dco 94I � 4b c3M <br /> Comments Included: 0 - -- - - - — <br /> Business Rep' nature Phone Number. Inspec s Signature hone Number <br /> INSTRUCTIONS ON BACK ► rreC' C hh� Incorrect: X A P L ; 1 '.2' 3 62081 <br /> White C py:CIW Yellow Copy:Operator Pink Copy.LEA _ <br />