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Inspection Report Number <br /> ■ Waste Tire Sui Bey & Inspection Repo, t p p ■ <br /> "' CIWMB 181fornia <br /> (New 04104) Survey Form - Page 1 Il - 1143682 <br /> California Integrated Waste Management Board .7 <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Ct Inspection Type (Fill one) <br /> Site Suffix: ' L� ( Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: U� CCUn Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical A ress �3 -- 1 Q ( ,o ,,,,C�J(„ <br /> CA q Inspection Date ` <br /> F �C� 5336 Time In (� <br /> 11� Time Out ( C� <br /> Business Rep TitleO AM C/ 7 O AM <br /> 3 : 5 © PM 7 ' vC PM <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 /> ' 0 Active ® Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> D Q Inactive Q 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 I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§4295 - Q Notice Of Violation Q Extension <br /> 1 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 O - - <br /> 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> �U►�nlie,�t — — - --- - --- - --- -- <br /> Inspection Form Included: Q <br /> Comments Included.® - �--� - - - _ c71 Z^<-16 <br /> Business Rep's Signature Phone Number sp for S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect is r 13 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />