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Waste Tire Su, ;y & Inspection Report _inspection Report Number <br /> State CIWMB California I 1 - 114 0 6 21 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey - - - - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z y ,� a 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C'L Yu Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Na Inspected By Inspector <br /> G A� 3 <br /> Physical Address - f / <br /> // � <br /> J Inspection Date <br /> S t C41_1en/ G <br /> /_15 Time In Time Out <br /> Business Rep Title _ O AM _ Q AM <br /> / ® PM 1 2 3 PM <br /> l..Qnra-Ck,a 0-wY1e <br /> - - - - - <br /> Operation <br /> onal Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f �j, (Fill y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / O Active ® Passenger j • Generator ® Outdoor <br /> -- - 0 Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler --o-hdoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) j <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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> h V A` 'HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / <br /> m / m <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 f 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 <br /> In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments k N� )nyeC;6e-A=,--l.Tk '-q-ti-i <br /> Inspection Form Included: Q <br /> Comments Included: ® -- - <br /> Busln ss Rep's Signature Phone Number spector's—Signat- u-r_---_- Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X "�- v 11F A P I&A 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: A <br />