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Waste Tire Su ty & Inspection Report inspection Report Number <br /> State CIWMB California I 1 - 11410 4 2 <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- Inspection Type (Fill one) <br /> Site Suffix: 4 4 O 0 - 0Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sc,%n `�t1c,� ,���� un,��a Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name —U - — Inspected By Inspector <br /> Physical Address 3 - [ F�C�►�1Mt�r�?UI1-,`e�r— <br /> 40c t- CA q5 ao <br /> Inspection Date 09 <br /> 5 C <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 6 <br /> J ( n � 0 PM v 0 PM <br /> —_ - -- ---- — -ep- <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 /> f ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered ,Nj <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all.that apply) - _ - — - --- --- <br /> p New Tire Dealer p 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 <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> ._... Q Notice Of Violation Q Extension <br /> - ----.�___..�_._..._- ._..._..., <br /> Q O ' PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q I 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 <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 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 ® In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments n -T1 <br /> l 1� t,.faS <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business p's Sign Phone Number spe�gnature Ye Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X A'M p 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />