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E:= <br /> Waste Tire Sul, - .:y & Inspection Report Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 3 8 3 6 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey __ _--_- - __ _ BLUE OR BLACK INK PEN_ <br /> ----------- <br /> Business Profile Inspection Details <br /> TPID- � � � � � � - � I Inspection Type (Fill one) <br /> Site Suffix: _151 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> fle�ZM(f, <br /> Physical Address j _ l Q i Ammbui <br /> Li(:c> 0,eXn_" par K LOC&Lf <br /> , 1 l <br /> Inspection Date <br /> Z-c;J itis C� 15330 <br /> Time In Time Out <br /> Business Repl A / Title I ®AM /•� C) Q AM <br /> / ! �f� � o PM Z, V-- — � *PM <br /> 441�1'1 - <br /> - — - -- ---- <br /> e <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 /> ®Active Q Passenger ® Generator Q Outdoor <br /> GPSLatitude O Q Closed Q Altered Q Hauler Q Indoo/r <br /> � <br /> O Q Inactive ®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 ® Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS <br /> j <br /> V-1 - HAULING AND MANIFEST REQUIREMENTS <br /> Q Q I Q Notice Of Violation Q Extension <br /> 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 1 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 010 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 /> 1010 Other: § <br /> Comments <br /> Inspection Form Included: <br /> Comments Include -- -- - - <br /> B iness Re s nature Phone Number pdc 's Signature Phone Number <br /> _ - --- <br /> - - <br /> INSTRUCTIONS ON BACK rrect 0 Incorrect: X +� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:LEA ® ■ <br />