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Waste Tire S y & Inspection Report )spection Report Number <br /> Il State CIWMB California I - 114 0 717 <br /> grated 1steManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> j Business Profile Inspection Details <br /> TPID- t, Inspection Type (Fill one) <br /> Site Suffix: ` C Z L 9 / - 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> S k� �-- <br /> f�WV <br /> Physical Address -/,3 O / <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title © I 0 AM 0 AM <br /> C <br /> 11 d 0 P PM <br /> - <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 /> f 2 S ®Active 0 Passenger 00 Generator , Outdoor <br /> Latitude Q Closed 0 Altered <br /> �, --- -- -----o -- 0 — -1D-indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 End Use Q Container <br /> 0 Planned I*OTR <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 /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> - 0 <br /> .......... Notice Of Violation 0 Extension <br /> - _ - —. <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 10 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m , m / m <br /> 0 0 ! 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> i <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 Q Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 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: 0, <br /> �• -Gv� OxoZ�' <br /> Comments Included: z0, L,(' <br /> Busines ep's Signature Phone Number Inspector's Signature Phone Number <br /> —--- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X _ 12131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />