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.I:t= Waste Tire Inspection Re Inspection Report Number <br /> y p 0 <br /> State B California 11 1127730 <br /> CIWMB 18ast(Now <br /> Manage) Survey Form - Page `i <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J e Inspection Type (Fill one) <br /> Site <br /> Site Suffix: , IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1� � �/_1 If Referral,choose referral type(Fill one) <br /> Identifier: V��/ t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I Inspected By Inspector <br /> one kVk 0 S nnZ� l I �Il <br /> Physical Addres 3 c l l O ` <br /> _ Inspection Date i 1 / 0 cl <br /> � <br /> aa act Time In Time Out �/ <br /> Business Rep y 1�, Title 0 AM 0 AM <br /> ® PM— p2 � � 0 PM <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 /> •Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude e 0 Planned 0 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 /> ®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 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 m <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 � <br /> 6 c� <br /> /too i k_*' 2mss c - ���� c c�r� <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Uk <br /> � <br /> ep'sSignature Phone Number ri ct r' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: XJ"PinWkC �Z' <br /> 112131s2081 <br /> 0 White Copy:CIWMB Yellow Copy:Operator ® ■ <br />