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Waste Tire Su► ay & Inspection Report -Inspection Report Number <br /> State B California Il - 1140759 <br /> Cgrated Waste <br /> eManag) 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- Inspection <br /> , Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J CvvCQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name G Inspected By Inspector <br /> r- <br /> /G ys Zt S <br /> Physical Address 9 G <br /> y- A _ <br /> Inspection Date ( C) r Q <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> C 0 o? 3 � ® PM 3 � � ®PM <br /> J wI, - <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 /> ' 0 Active Q Passenger ® Generator 0 Outdoor <br /> Latitude Q Closed Q Altered <br /> GPSj Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck j <br /> Longitude j Q End-Use Q Container <br /> 9 - Q Planned 1 Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 <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 j HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> I (Required for NOV or F_XT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q X <br /> Comments Included: �Rep'sgnat;ure <br /> -- �2P9� �6Y�� ZBusiness Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X p 2 62081 <br /> ■ <br /> White - - - — ® ■ <br /> Copy:CIWMB Yellow Copy Operator Pink Co <br />