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ax <br /> Waste Tire Su.46y & Inspection Report inspection Report Number <br /> C'm Stale c1WM `i;1 New Survey Form - Page 1 - G 7 9 9 1 <br /> CNVMB 181(hew 04104) <br /> callfomia Integrated waste Management Board <br /> Part A-Surve BLUE OR. BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � - Q / Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Locali If Referral,choose referral type(Fill one) <br /> Identifier: 42"L- 0404 4.� H �¢�`' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` <br /> � Inspected By Inspector <br /> Physical Address <br /> Inspection Date � � � Q � � co 9 <br /> G I / Time In Time Out <br /> Business Rep Title S ® AM 0 AM <br /> 0 PM 0 PM <br /> d` Operational Status TireType Business Role Storage Type <br /> Tire Count (Whole/PTE) n D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> n� ® Active * Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS <br /> _-,-- —.-----_-- -- _--- -- _-- <br /> V A - Q Notice Of Violation Q Extension <br /> Q O 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 E] M M` <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q -------------- <br /> 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/CIWMB 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 /> QO Other: § -- - --——`---=--- - --- <br /> Comments <br /> � s �* 4 �/ /mac-�oz•� /cc/�gy r 7''� C�%� f <br /> Inspection Form Included: O ( � <br /> Comments Included: Q <br /> &. ature Phone Number Inspector's Signature Phone Number <br /> �\ � 62081 <br /> INSTRUCTIONS ON BACK Cotc <br /> t: / Incorrect X '"� e X A P L. 1 2 3 <br /> White CopyYellow Copy:Operator Pink Copy:LEA <br />