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Waste Tire Su_ . ,y & Inspection Reports Inspection Report Number <br /> State CIWMB California I 1 - 11412 51 <br /> grated asteManage 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- Inspection I Inspection Type (Fill one) <br /> Site Suffix: y 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CM J041ujn 1a Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name D I 1 n Inspected By Inspector <br /> Physical AdU� 1 '�� lf7r ) _ <br /> W <br /> _�,5Inspection Date <br /> Of <br /> CA 3jb Time In v Time Out <br /> Business Rep TitleO AM Q AM <br /> PM <br /> ' I O � 01 � 0 PM <br /> -- - - - Operational Status Tire Type Bu <br /> Tire Count(Whole/PTE) siness Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f <br /> • Active Q Passenger 0 Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 4 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 /> V A 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 /> Q Q 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 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 O 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 O Other: § ( _ <br /> Comments _T 1 i Oa k V 1S Gf� ovd'`1q kA r,S nA4f <br /> Inspection Form Included: <br /> Comments Included: <br /> Bus' kR—ept S gnature Phone Number Inspector's Sign pre RKone Number <br /> INSTRUCTIONS ON BACK Corr . , , I orrect. X Q1-1M23 62081 <br /> WMte C ny 'eliow � oy:Opeiator pink Copy:LEA <br />