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ms® <br /> Waste Tire Sui&y & Inspection Report Inspection Report Number <br /> State CIWMB California I 1 - 112 7 5 2 0 <br /> grated 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 j Inspection Details <br /> TPID- � � �j - � I Inspection Type (Fill one) <br /> Site Suffix: 1 ` I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r- 1 If Referral,choose referral type(Fill one) <br /> Identifier: S� Jo Ld(� �0 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address }} <br /> �� QSaU b Inspection Date I l <br /> �f1 Time In Time Out <br /> Business Rep Title0 AM I L{ 0 AM <br /> ' S s PM { 4 ®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 * Passenger is Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 i 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 QPRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 Q Other: § - <br /> Comments I VLy3 _ Orl 06A �� ��— l Y/` '�0�_ 1__ u5 now'. <br /> '. <br /> — <br /> _-A - - f _s sic_ mu �crkc1 us _6�1r <br /> Inspection Form Included: Q /� 0 �r�.Sijn.t <br /> Comments Included: Q 7e/1�1, (�J --- ___ _ . _Business Rep's Signat a ` Phone Number Inspure Phone Number <br /> INSTRUCTIONS ON BACK Correc ; correct: X ` �/�� � } fL P (� ��� 62081 <br /> - to <br /> White Copy:Cl Yellow Copy:Operator Pink Copy:LEA <br />