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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State 8 California 7 1 0^8 0 8 7 <br /> Cgrated asteM nage Survey Form Page 1 1 VX VX VX <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- >j n Inspection Type (Fill one) <br /> Suffix: XV `il <br /> Site l *Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ^ ,T� \ If Referral,choose referral type(Fill one) <br /> c <br /> Identifier: a(\ vLd n Cou J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J <br /> D� � Inspected By Inspector <br /> O— Q /' <br /> Physical Address - ( 4 ` `-C„ f"�A <br /> 10�. �a(15b n Q (% l� r� <br /> i f\ Inspection Date I U <br /> L�a� f�JrLil Time In Time Out <br /> Business Rep Title <br /> �_(�:,r-1^ Title : 1 ' S AM ' O AM <br /> s�1 �-i�n� `�1 1_�- f ~` 5 O PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> B Active ®Passenger Q Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <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 <br /> m / m / M <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 ori9Cn <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/CIWMB Enforcement <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 S in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments INSQ�(on Ao( o(4�� 4- �4 ou I n9 0A �J <br /> (`U utt6�a�`tO�S c9C �,cuis lt� C�{1(StSn - <br /> N�e <br /> Ins ection Form Included: >/�' /f�/y {q Q <br /> P Comments Included:0 (�`+ C�O� <br /> Busi ss Rep's !ignature Phone Number Inspec 's Signature one Number <br /> INSTRUCTIONS O CK Corrreordl Incorrect.X � N/ E X I A MI P I L E11121311 62081 <br /> ■ White Co, CCW h1 Yellow Copy,Operator Pink Copy.LEA �� ■ <br />