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Waste Tire Su. :y & Inspection Repo rtonspection Report Number <br /> State B California Il - 1140696 <br /> Cgrated 1(New <br /> Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLU_E OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I Flu- q Inspection Type (Fill one) <br /> Site Suffix: S 1 - I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SrX v� +�ciq(f u,ty� I 0 CHP 0 CIWMB— 0 Complaint 0 Educational Visit 0 Other <br /> Business o`r-Facility Name) Inspected By Inspector <br /> Physical Address <br /> l0 I ' 1 - ,vD� QA <br /> f 1 ` _ Inspection Date Q Q <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> d 3 O 0 PM -3 I ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) 1 (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) t f <br /> 0 Active ® Passenger ® Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive I* Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <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 /> 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 ep Other / f <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 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 <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 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 In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments ', ,�_- • I, -�7 / <br /> �1L�`yvlt, <br /> – t1j4L{ PW � 5;� CCIYVll�L2l <br /> -- <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number ector's Signature b Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X c X A E 1 3 <br /> While Copy.CIWMB Yellow Copy:Operator Pink C y:LE <br />