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�tWaste Tire Su. :y & Inspection Report Inspection Report Number <br /> CIWMBState of California Il - 1140655 <br /> asteManage Survey Form - Page 1 <br /> Callfomia 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: r J Q —2 SCD ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t �, <br /> GM "� — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected B <br /> P y Inspector <br /> 1�b� S l c-.t♦ c�i J�,�c- . <br /> Physica Address 3 <br /> :3fo1 c�� r <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> 0 AM Q AM <br /> [[►► 0 O 0 P G 3 0 ® 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 /> f 0 o Active ® Passenger ®Generator Outdoor <br /> O Q Closed Q Altered <br /> -- -�7r� Latitude — - -� --- -- --- Q Ranter- - - <br /> �flldOol�— <br /> O Q Inactive •Truck <br /> Longitude _ Q Planned ®OTR 0 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- ---- - --- --- -- - - -- O Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 00 <br /> 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 <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 I 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 f� <br /> �ld.lt,� •Fyt ST�'l"'c�'�'J 6M�c - �(�t.'�.p !'� � Q ---- - - - <br /> -- <br /> Inspection Form Included: Q <br /> Comments Included: ® � '��J �ti�Nu:bt <br /> Business 's SignaturePhone Number nspector's SignaturePho <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �( ,. X A' �. <br /> p 3 <br /> 62081 <br /> VVhite Copy:CIV°dAlb Yellow Copy:Operator Pink Copy:Lt// <br /> A <br />