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Waste Tire Sural*& Inspection Reportftpection Report Number ■ <br /> State of California I 1 - 1140633 <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> -t A- Survey_ - BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> I PID- Q f Inspection Type (Fill one) <br /> Site Suffix: O 3 1 5 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CA_ wAsr, <br /> Physical Ad ress &A-) ES CORO <br /> rr <br /> CA q ls' TM Inspection Date b + rl <br /> �i�L✓� J J Time In Time Out l V <br /> Business Rep Titleu 0 AM { /, O AM <br /> 1 <br /> t I I l 5 O PM V V ® PM <br /> I <br /> Sup�V� S flr' 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 /> Q Active Q Passenger • Generator * Outdoor <br /> t7 $ Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude — End-Use Q Container <br /> Q Planned OTR <br /> Business Type (Fill all that apply) <br /> Vew 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 / p <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other (�JL �I 1 '(a4 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 1 <br /> 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 /> I <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / 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 1 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 j In Compliance - No Violations <br /> Q Q Other: § <br /> Comments __ i e..,f S1 1 tau_q II <br /> wt s- n o_ _eel'- -- - - -- - - ---- <br /> I. pection Form Included: QjZ' Ial <br /> J <br /> Comments included: 0' aoF t3y- 119174r Cusmess Ree Phone Number Inspecto Signature Pone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect i l 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />