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Waste Tire Sui ;y & Inspection Report Inspection Report Number <br /> State of California <br /> Cgrated 1(New04/04) Survey Form - Page 1 Il - 1140826 <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: :il (9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> U .c-c w�.� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ✓ Inspected By Inspector <br /> Physical A� C�YI r2>S C 7 <br /> u /'9`7ti�k:N'tG� <br /> Inspection Date <br /> r 3 3 <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> D O PM 3 O PM <br /> (Fill ne only)onal Status (FII ireThat apply) (Fill all that apply) (Filess Role o)alge Type <br /> that apply) <br /> Tire Count(Whole/PTE) (211 <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 Q Auto Repair ® 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 /> 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 /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 ® In Compliance - No Violations <br /> Q ! Q Other: § <br /> Comments <br /> wu r AV 111::d <br /> Inspection <br /> mme is Included: ®' <br /> Business � -- � -- - - <br /> Rep's Signature Phone Number nspector s Siyn re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X i F X A'�d4 P � 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />