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Waste Tire Sul, - _y & inspection Report aspection Report Number ■ <br /> State of <br /> 81California <br /> Survey Form - Page 1 I 1 - 1143830 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5 vt v C� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � /��,�L.�,, J If Referral,choose referral type(Fill one) <br /> Identifier. �-�J 1 `rl 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> � Inspection Date C� to <br /> G?__ � �� Time In Time Out t/ <br /> Business Rep Title �ry 0 AMff }} ®AM <br /> G (.� O PM C.✓ QPM <br /> Lo v1 s bar wIcv� O&m&r - - - <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active 0 Passenger 6)Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive Truck <br /> Longitude – 0 Planned 0 OTR j 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 'PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities – <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 1 Q 1 Other: § ----_—_-- <br /> Comments.�.� r _ Wd�e� <br /> t <br /> A4 C, <br /> C� i!'U S cSY �eryl CE' <br /> Inspection Foran Included: 0 <br /> a () <br /> Comments Included: 0 - ----- C17 <br /> B siness Rep's Signature Phone Number Inspect 's ign t re Phone Number__ <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect X �� E X A 41 1111213] <br /> ■ White Copy:CIWMB Yellow Copy:Operator PinkCCV201 ■ <br />