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_ Q9182 �50021 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> ° site of11CaliforniaN �I 1 - 1108460 <br /> Cgrated asteManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board � <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I _ ^ Inspection Type (Fill one) <br /> Site Suffix: o -I� L/ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �r-r+,r, , „1� <br /> v��,�`�lJ�ti�► Q CHP Q CIWMB Complaint Educational Visit Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address LILoill <br /> Street _ —I <br /> Inspection Date <br /> �5aoW <br /> City �tata LIP COt!a Time In _ Time Out <br /> Business Rep Title <br /> - -i- I-• -I - �v2- Q AM Q AM <br /> ®PMjoaPM <br /> A-ft <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> ,(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Count(Whole/PTE) O <br /> ®Active O Passenger ® Generator O Outdoor <br /> - -- - O Q Closed O Altered <br /> GPS Latitude O Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer 0 Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler O Agriculture Q Shredder O Other L <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS Notice Of Violation <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ® ce on Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB a / Fll� I&N <br /> O O 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 /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Other: § -------- —--- --- -------— _�._� <br /> Comments C .tea /• ��e�� <br /> Inspection Form Included: ��- TO��^� <br /> Comments Included: 9 T �/ <br /> usiness ReQp'sAignrPhone Number In o i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS.ON BACK Co ect: ncorrect: ( X g M P L E 1 2 3 <br /> White Copy: IW MB Yellow Copy:Operator Pink Copy.LEA <br />