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Waste Tire Sui Bey & Inspection Report Inspection Report Number <br /> State CIWMB California I 1 - 114 3 4 6 9 <br /> grated 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 /> TPID- q hh Inspection Type (Fill one) <br /> Site Suffix: 1 4 1 - V IS Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: S(�{��Ioa�Lun (l7,Lur� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> k%Z" w7i00 3 9 <br /> Physical A dress <br /> -Sao 5 <br /> ��•� �A �5a�l'0 Inspection Date 0 / 1 V <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> 3 ® PM I ® PM <br /> n - + Q 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 /> > > 1 <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> O • Closed Q Altered <br /> GPS Latitude Q Hauler • indoor <br /> O Q Inactive Q Truck <br /> Longitude - I OTR Q End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 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 r , <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other PvC pl' L q'An T,& (C <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / 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 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 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments � �Ae..I CN L J11_I'��S �•�. <br /> Inspection Form Included: <br /> Comments <br /> Business Rep's Signa Phone Number Inspec is Signature C -Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: . la XTp� f -r� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />