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Waste Tire S%eY & Inspection Re Inspection Report Number <br /> = , p p <br /> State CIWMB California I 1 - 114 3 7 0 9 <br /> grated 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- l 7 ,1 <br /> � Inspection Type (Fill one) <br /> Site Suffix: f Routine Q Re-inspection Q Referral Q Observation <br /> Local �l 1 If Referral,choose referral type(Fill one) <br /> Identifier_ SI n 1 'G �I n —/ Q � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1. Inspected By Inspector <br /> Physics Addre <br /> e-S ss 5 o�w 6v� -(�r c, 3 ! - ( 0 <br /> M 0 mc,�Cnf Av c-. a <br /> Inspection Date <br /> �&t& o C A i5-32D <br /> Time In Time Out <br /> Business Rep Title j� O AM 5 O AM <br /> 0 P ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /= 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (� ®Active ® Passenger If Generator ® Outdoor <br /> -------- O— - <br /> GPS Latitude Q Closed Q Altered <br /> • Hauler 0 Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — Q End-Use Container <br /> Q Planned ® OTR <br /> Business Type (Fill all that apply) <br /> ® New 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 <br /> Q Service Station ®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 I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§ - Q Notice Of Violation Q Extension <br /> 42951 Waste Tire Hauler Registration and Transport of Tires <br /> I <br /> Q 1 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 1 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 14 CCR M / m / m 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 EX7) <br /> Q Q <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 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments � I I �rN r i <br /> (inspection Form Included: �1 <br /> Comments Included: a, -- <br /> 'J.p�t 3s3� -3t4 <br /> Business Reps Signature Phone umbe Inspec is Signature hone Number <br /> - -- <br /> INSTRUCTIONS ON BACK Correct:0 incorrect ( M P fi 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA r— , ® ■ <br />