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Waste Tire L.a. .ey & Inspection Repap Inspection Report Number ■ <br /> CIWMB81California <br /> CIWMB Survey Form - Page 1 I 1 - 1127672 <br /> California Integrated Waste Management Board .7 <br /> Part A-Survey BLUE OR BLACK IN PEN <br /> Business Profile I Inspection Details <br /> TPID- 1 6 C c2 _ Inspection Type (Fill one) <br /> Site Suffix: O Routine Q Re-inspection • Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� L/M �vvr L Q CHP Q CIWMB ®Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r <br /> Physlca Address 39 1 <br /> 0-ts1 E. <br /> Inspection Date / � c2 �5 <br /> Time In i Time Out <br /> Business Rep Title ] ®AM O AM <br /> ,-Y�1f �� �r\1�- / l PM a WPM <br /> 1 b 1 r f�t l�W� (� I� — ---------- <br /> au ---- - <br /> --- - -- —" ' � - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �j/' © c (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' o Active ®Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 1@ Hauler O Indoor <br /> O 0Inactive Q Truck <br /> Longitude - 0 End-Use ® Container <br /> 0 Planned Q OTR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V T A HAULING AND MANIFEST REQUIREMENTS <br /> ® Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle -W <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / / <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB 11G <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 0 Q Other: § <br /> Comments <br /> Inspection Form �ncludecl: *_. <br /> ncluded: <br /> C� / / C <br /> Comments - � -- -�� 1 - �l��t+ _ ... ��J - ��_ <br /> Bu 11.4ess Reps Signature- --- -PFtOne Nu bei s e ignature- Phone Number <br /> - s - - —--- - -- <br /> INSTRUCTIONS ON BACK Correct: Incorrect NY '"� �/1 � A p � 11 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py:L <br />