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Waste Tire Sui J & Inspection Report spection Report Number ■ <br /> State of California <br /> CWMB grated 1st(New <br /> Manage Survey Form - Page 1 11 - 1140996 <br /> California Integrated Waste Management Board <br /> Part_A-Survey _ _ BLUE_ OR_ BLACK INK PEEN_ <br /> Business Profile I Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> ffi - —- - <br /> Site Suffix: ® Routine O Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cav� a,uv�� 0 CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name lT <br /> _ Inspected By Inspector <br /> Physical Address a <br /> Inspection Date 1 C) / C) tl / Q <br /> C!� �7 5 31 t1 I 1 <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> d oZ I S • PM 0 3 d O ®PM <br /> v�CLff ---�- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ( I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> *Active O Passenger 1* Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O O inactive ® Truck <br /> Longitude - O Planned Q OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader 0-Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle m <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 Other: § - <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: * i - fi(ik G�-O6Z <br /> Business a 's Siggpature Phone Number spector's ature Phone Number <br /> ` 62081 <br /> INSTRUCTIONS ON BACK Correct: /fn/correct: X ' � E X A, P 3 <br /> f <br /> While Copy- �16"J �'� Yellow Copy Operator Pink py:YVI"*' <br />