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® = _= Waste Tire Sevey & Inspection Repo" Inspection Report Number <br /> '� - State of California I 1 - 1141309 <br /> Cgrated Waste <br /> eManag) 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- c Inspection Type (Fill one) <br /> Site Suffix: J 3 � Q �� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �� ` 1 �/ If Referral,choose referral type(Fill one) <br /> Identifier. '�� I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I)' e4� ► o er�, Ty-ujAam <br /> Physical Address V \ - A�6r-L✓ <br /> ^ r+ Inspection Date Q G! <br /> ���`V► 1 ``�� Time In Time Out <br /> Business Rep Title -, <br /> f�� - ® PM C� � � PM <br /> Rao � � �� !i Op ® <br /> erational Status1 Tire Type Business Role Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill,, that apply) (Fill all that apply)T(Fill all that apply) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> 1 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive IV 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 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 EX7) <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 /> Q Q Other: § <br /> Comments <br /> -- - fitoby r <br /> - - - - -- - a <br /> ^-fir- -- i <br /> n bd - <br /> Inspection Form Include : Q <br /> Comments Include <br /> Q Busin s Up s Si Ra re ne Number -In or's ture Phone Number <br /> , 62081 <br /> INSTRUCTIONS ON BA or U -g` !> 'h�PT7 11, 12131 <br /> White Co :CIW Yellow Copy:Operator Pink Copy:LEA <br />