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09� 950��485 <br /> Waste. Tire Survey & inspection Report InsPection Report Number <br /> StatLE CrW B 81(New <br /> Il - 1108500 <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 <br /> Califomfa Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile �—�-, Inspection Details <br /> TPID- n 1 41 o I - I _ i I Inspection Type (Fill one) <br /> Site <br /> Site Suffix: ILLL t IL ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �qaa, /fin / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V " , Inspected By Inspector <br /> Phy EX_ YAG. i - 1 1 0 111 <br /> LA 6m_130-1,1,1 <br /> L_A1-cl O R_cr 1,v_\_ <br /> Street1 <br /> (� <br /> 5R-130-6 Inspection Date <br /> LLcth ro_/" �� Time Time Out _ <br /> City Stag ZIP Codi <br /> O AM <br /> Business Rep Title /� 131 <br /> AMV ® PM <br /> -- � '. 3i QPM <br /> - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ <br /> f Active Passenger' Generator <br /> ® Q ® Q Outdoor <br /> GPS Latitude I 10 Q Closed Q Altered <br /> • - _ , i Q Hauler ®Indoor <br /> Q Inactive ®Truck <br /> —i-- =I --:=-=;0 <br /> Longitude - I i - i j Q Planned ®OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 ®Other LUi�S�1 Com/<�G <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required fo NOV or EXT} <br /> i <br /> Q Q .14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I C-IWMB Enforcement <br /> Q O 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 ®tn Compliance - o Violations <br /> Q Q Other: § <br /> Comments ms v P -L,J� �t �/►_ <br /> lIL � 1 i'1 1 <br /> -- <br /> -b--VQ)IG, <br /> Inspection Form Included: Q <br /> Comments Included: Q �Ve <br /> s Hess Rep's SI lure Phone Number tns f s ure. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co ect: I correct: X A Nt P �L 1 I Z 3 . <br /> White Co .CIW Yellow Copy:Operator Pink Copy.LEA ® ■ <br />