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"18Eu <br /> Waste Tire Su&y & Inspection Report"Anspection Report Number ■ <br /> State of California <br /> _ • C 1( e ) <br /> California Integrated Waste Management Board Survey Form - Page 1 1127586-1 <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> A <br />( TPID- / � _ �^� � I Inspection Type (Fill one) <br /> Site Suffix: ll C}i "� 3 Iq <br /> f6 (-J� o Routine Q Re-inspection 0 Referral o Observation I <br /> � V <br /> Local -- If Referral,choose referral type(Fill one) <br /> Identifier. R O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name j <br /> Inspected By Inspector <br /> 1 1046(yt O F\ I nn 9 <br /> Physical Address ES(4) <br /> S:reO <br /> /] 05 Inspection Date <br /> Crty State ZIP Code Time In _ _ Time Out <br /> Business Rep Title I0 AM °AM <br /> F5 c� <br /> PM I (D PM <br /> Operational Status Tire e YP <br /> Type Business Role Storage T, <br /> Y g <br /> Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count <br /> ❑� i <br /> Active Q Passenger Q Generator Q Outdoor <br /> Latitude <br /> i O Q Closed O Altered <br /> GPS j Q Hauler 11) indoor <br /> _ � Q Inactive (5Truck <br /> Longitude — i j Q Planned 0 OTR O End-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel j <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer o Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other 11 U fy>0a It 1-1 � <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> VT A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation�Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / .m / El <br /> Q O 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 /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years r <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 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 O in Compliance - No Violations <br /> O O Other: § <br /> ' II <br /> Comments <br /> u ( � k,� A hC <br /> Inspection Form Included Q! r/, ,�/ <br /> Comments Included Y in <br /> _ -art j <br /> i Bu tfss Rep's Signature Phone Number Inspector's Signature Phone Number 1 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ; `!,., 62081 <br /> ■ _ ■ <br /> White Copy:CIWMB Yellow Copy:Operator .Pink C py: <br />