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Waste Tire S%y & Inspection ReporrrL %spection Report Number <br /> State of California 1 - 1088335 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 �_ _. <br /> California Integrated Waste Management Board - --- - <br /> Part A-- SurveyBLUE R BLACK <br /> Business Profile Inspection Details f <br /> - Inspection Type (Fill one) <br /> TPID- F <br /> Site Suffix: + Routine 0 Re-inspection', 0 Referral 0 Observation <br /> Local , If Referral,choose referral type Complaint <br /> one) <br /> Identifier: ), „ i �- t.+ Q CHP Q CIWMB Q Com �aint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector l - <br /> Physical Address <br /> ! <br /> ! t.Ld <br /> l <br /> i ' ciCl : � i h I <br /> — _ <br /> freer -- �.t F�_� � <br /> Inspection Date I <br /> State GIP Code Time In _ Time Out <br /> Business Rep Title � , � Q AM '- — - Q AM <br /> 0 PM O PM <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 /> I <br /> Tire Count (Whole/PTE) ' � <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q_OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Deal-er Q Auto Repair Q 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 i�✓Gte ; <br /> --r- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS a <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 /> 10 O 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 / 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 EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities l _ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q Other: § <br /> Comments <br /> UC <br /> {"�(✓{f !rI I �1 ��1.0 r (�(� "` -��.ICf :.1 tiv 1 C►�lp� �'+f��� ��t'ri�� �("�. �.,I(a' <br /> IU E! 1 �rC��e —4 �i' :k ( ? �1. I t /� ,_ /'Gt rt r r T, <br /> , <br /> - - ` <br /> �('�i . ! 1 - <br /> t:'T ✓l'Yl tc a Clic `: , f e r_ 1 0 r''1C-( nn( <br /> ► '� ti, t �F.ic _7 a✓I- <br /> - <br /> Inspection Form Included: Q <br /> Comments Included: Q " <br /> Business Reps Signature Phone Number Inspector s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ✓ P_ <br /> INSTRUCTIONS 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />