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Waste Tire Su^ Inspection Report 4mction Report Number <br /> ■ eii <br /> State CIWMB California I 1 - 114 3 7 6 5 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA-Survey _ _____ __ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( Inspection Type (Fill one) <br /> Site Suffix: 30 ' 3 3 o I Q Routine ®Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S401 (,��(� ��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �11 &U T[aa5pirv(Al'or% '9�4t'm 2 0 <br /> Physic Address C�1 <br /> kO n � /�(�J�Ht 1(5-11S Inspection Date <br /> SOV\YL Time In Time Outt' <br /> Business Rep Title /'� O AM O AM <br /> ' V 9 PM ` O 49 PM <br /> --. <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 41 <br /> Active Q Passenger ®Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <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 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 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 <br /> Q Q14 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 <br /> 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 /> Q Q Other: § J <br /> CommentsV I D S 1 YAGIID "1 n <br /> fillL tit , <br /> - — Vsl�ness <br /> Inspection Form Included: Q <br /> Comments Included: Q -S—g <br /> -n-a--t-u-�r-we ho--n--e N�Lu�m—b=e-r" Insp or' Phol�ne Number umber <br /> - - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: c l E' X A P 11213 <br /> 0 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py:L ® ■ <br />