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434168Q5 000U <br /> eee: <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> NSlate of California <br /> 04 <br /> California Integrated Waste MaS 181(NowOnaO ment Board Survey Form - Page 1 , Il - 1088469 <br /> 'art A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ('j I I _ Inspection Type (Fill one) <br /> Site Suffix: J_iq0 Routine Q Re-inspection Q Referral Q Observation <br /> Localt �l )))1 If Referral,choose referral type(Fill one) <br /> Identifier: Sa �In __ I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> (\a T' <br /> Physical ddress. I I I UjQjj <br /> 6e, <br /> oil. V ffl <br /> srrc--r <br /> /► Inspection Date <br /> Str �1P CodQ Time In Time Out <br /> Business Rep Title I I i O AM r— I , ' I ` Q AM <br /> PM 48 PM <br /> __M(A ��Q - - Operational Status Tire Type Business Role Storage Type <br /> - <br /> Tire Count(Whole/PTE) (Fill one only) -(Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive 9 Truck <br /> Longitude – ,.i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 I i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E_, ',(I '��/(E TU STATUS <br /> rVIVAURW0130GYMONAN rtRZretuUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance .5 line <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 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days Required for NOV or DCTJ <br /> 0 10 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!C-IWMB 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 Q Other: § <br /> k—. Tom'^`-"�� <br /> CommentsQ-011I t <br /> .0 (OV-11 I- <br /> 1.1F A-/(- Zl' SS (�L�t5�, <br /> tC( 3 — a_ ���0�--�00$O�e�-� -O��u,��r� �e. for <br /> -A--cuts—M-0 bt- cc_l�t't_ <br /> Inspection Form Included: Q D e <br /> Comments Included: �0 1 �a� � <br /> Business Renature Phone Numberure P_hone <br /> ps 41nspe 'sSignatNutuber <br /> INSTRUCTIONS ON BACK InoE XAMPLEI Il23 <br /> 1 62081 <br /> pyCIWMWhite <br /> Yellow Copy.Operator Pink Copy LEA <br />