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03217040032 <br /> t == Waste Tire Survey & Inspection Report Inspection Report Number <br /> HBA- <br /> ;o State of California - I 1 10 8 6 9 5 0 <br /> ew 104) <br /> California Integrated Waste Management Board Survey Form - Page 1 - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site - _ O ( Inspection Type (Fill one) <br /> Site Suffix: 1111 I Routine Q Re-inspection Q Referral Q Observation <br /> Local �' 1 If Referral,choose referral type(Fill one) <br /> Identifier: uI � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> 9-i <br /> Business or Facility Name Inspected By Inspector <br /> Waw -U� A_I� r mcsn Spe�r��iS�� <br /> Physical Address — <br /> 9 <br /> F3T9 <br /> Street Inspection Date <br /> Cit State ZIP Code Time In Time Out <br /> Y <br /> Business Rep Title II )d <br /> . L�O a PM ® , D ®PM <br /> 0A <br /> Operational Status Tire Type Business Role Storage Type <br /> Fill one only) Fill all that a <br /> Tire Count(Whole/PTE) ( y> ( apply) (Fill all that apply) (Fill all that apply) <br /> A t ®Active is Passenger ® Generator ® Outdoor. <br /> GPS Latitude I ; ` 0 Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitudei 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 Q 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 /> V M HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice OExtension <br /> f lfiolation Q <br /> .0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 114 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 /> Q Q 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 /> Q Q1 Other: § <br /> Comments Lnw .1_'I V�_ � — � G,nA , <br /> '` --- <br /> { <br /> 3 6 r1 <br /> Inspection Form Included: Q7�; j ( ` t <br /> Comments Included: Q I r�' += <br /> Business Rep's n ure Phone Nu ber Inspe is ignati Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co reet: ncorrect: XJAIMIPILIE1 111.2131 <br /> White Cop .CIW Yellow Copy:Operator Pink Copy:LEA <br />