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Waste Tire S� .y & Inspection Reporlllnspection Report Number <br /> L..}81tda, State B California I 1 - 1140997 <br /> Cgrated 7(New <br /> Manag) 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 Type (Fill one) <br /> Site Suffix: 2T 0 4D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> � � Q <br /> Physical Address_� 3 / — / 0 <br /> ���n S �ic.S�.•� fid'• ��1�'� - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 2 2 PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r+'1 <br /> Active 0 Passenger 40 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude — 0 Hauler 0 Indoor - <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use i 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 a Othern -ry /� �� ;` <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS - <br /> --- _ --- <br /> i 0 Notice Of Violation 0 Extension <br /> 0 i <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 j 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 / m / m <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 EX7) <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 /> i <br /> 00 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 0 Other: § <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: _ _ ---- --- --- -�- <br /> Buslness Rep's Signature o e Number nspecto ' Signatu Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect Xt X A M P I 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy:L <br />