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Waste Tire Su By & Inspection Repor"L Inspection Report Number <br /> ��� State of California <br /> Cgrated 1st(New <br /> Manage) Survey Form - Page 1 I 1 - 1141284 <br /> California Integrated Waste Management Board <br /> Part A- Survey___ BLUE OR BLACK INK PEN_ <br /> Business Profile I Inspection Details <br /> TPID- / j Inspection Type (Fill one) <br /> � ,� � 019 <br /> � � <br /> Site Suffix: - <br /> Q e Routine Q Re-inspection Q Referral Q Observation <br /> LocalC I If Referral,choose referral type(Fill one) <br /> Identifier: � J( C,t("1 �l� L��17� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - - "- -(/ - --- <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physics dress 3 <br /> 1-180 E . Ufa se m �e /� -- <br /> Inspection Date <br /> ��it-�r� <br /> Time In Time Out <br /> Business Rep ,, Title O AM O AM <br /> I l e I/� I�UGI�Y� �� O O PM l : 5 O o PM <br /> ` - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) --y `� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` v 40 Active ® Passenger ® Generator ® Outdoor <br /> - <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - i Q Planned I ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - - -- -- <br /> Q New Tire Dealer Q 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 ® Other , <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 1 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 <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 /> -s I I D c oIIm - rte)cx+. -r1 D`fCc\ � <br /> 01 <br /> Inspection Form Included: Q <br /> Comments Included: Q - --- - ------ - - - 1� � G b 7- — <br /> 1 Business Rep's Signature Phone Number Ins or's i ature Phone Number <br /> INSTRUCTIONS ON BACKorrec ; vincorrect ; E x A,.Mh� P 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />