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Waste Tire Su► - ty & Inspection Report Inspection Report Number <br /> State of California Il - 1143770 <br /> Cgrated Waste <br /> eManage) 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 /> eInspection Type (Fill one) <br /> Site Suffix: (R, —7 1 a ( b Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: -�bl� � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - A6,lI Ur 1, c: <br /> b�� <br /> -nencInspection Date / <br /> hrn� c�1a3 <br /> Time In Time Out <br /> Business Rep Title I O AM C2 , l` `z 0 AM <br /> f r� 5- ®PM `-1 p� a PM <br /> r�'1C - - - - -- --- - <br /> --i — ----- ---- 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 /> ` 0 Active 0 Passenger 4b Generator I* Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ®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 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 /> Notice Of Violation 0 Extension <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 m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FX / Ms <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB III 111 111��� <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 /> 0 0 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> (54--t-s-- <br /> t e-,-- <br /> Inspection Form Included: OI <br /> Comments Included: <br /> iness Rep's Signa ure Phone Number Apcto igna re Phone Number <br /> - -- -- - _ <br /> INSTRUCTIONS ON BACK [Correct: Incorrect t VI E A Et 1 j 3 62os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y: <br />