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■ �=E Waste fire Su Ay & Inspection Repor, Inspection Report NIAmber ■ <br /> State of California <br /> California Int gr ed'81 Wast(New <br /> Management Board Survey Form <br /> o rm - Page 1• Il - 1127479 <br /> Part A-Survey _ _BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` Inspection Type (Fill one) <br /> Site Suffix: 35 � 1` l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , /► If Referral,choose referral type(Fill one) <br /> Identifier: t.J t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name /) Inspected By Inspector <br /> Physical A%*ss 3 <br /> 1 )gym <br /> Date <br /> ate <br /> I <br /> v C � v6 1 z <br /> Time In Time Out <br /> Business Rep Title O AM I416, O AM <br /> �yj Lo <br /> PM- 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 inactive ®:Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair I*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 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 / m / 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 1 0 1 Other: § <br /> Comments S <br /> 07 <br /> A/0 LIt blq_741�?�j oy <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> B in ep's Sjljnature Phone Number I's c o s nature Phone Number <br /> 4 11 <br /> INSTRUCTIONS BACK Correct:* Incorrect: I !, E AWILIE1 111213162081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />