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i. Waste Tire SLft & Inspection Repospection Report Number <br /> State B California I 1 - 1127660 <br /> ! Cgrated 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: / d 4-1 �1 C) 1 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local K If Referral,choose referral type(Fill one) <br /> Identifier: yl Cp,,/h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cin 1 1 l r <br /> 9 <br /> Physical Addres - a <br /> Inspection Date ` ) O <br /> Time In Time Out <br /> Business Rep Title @ PM O AM <br /> J Jam, l <br /> �(e,�- C/�-�Y���I� oF P M <br /> -- - ---- - - - - ------ 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 /> ® Active Q Passenger ® Generator a Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® 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 Q Other <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 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 / 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/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 I ��„ Compliance No Violations <br /> Q Q Other: § <br /> - - - - — -- <br /> Comments <br /> cj) ve'—M-�>f , -' 47-�—� <br /> L2 V Oy- X��i3 6 <br /> Inspection Form Included: Q -a-T/ <br /> Comments Included: Q 1G�f1!7 _C/� -�v-�- �Z� <br /> Business Rep's Signature one Number Ins ct is I ature -- Phone Number. <br /> - - -- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect X A I 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: <br />