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== Waste Fire Su0y & Inspection Reportolnspection Report Number <br /> 1'L3t <br /> State of CaliforniaCIWMB T 1141236 <br /> California Integrated tWaste 81 eManagement Board Survey Form - Page 1 +,1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ^'vµY M If Referral,choose referral type(Fill one) <br /> Identifier: 1_ ��1 s i�V € <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> .Business or Facility Name <br /> Inspected By Inspector <br /> _ T101 ! �- <br /> Physical Address , , ��� __• i ___ / <br /> _� f-----_-.;_--�-_•_; r --; r---�--w-•�-mss <br /> qtr\eef C � Inspection Date ... <br /> _ __... <br /> ff �ate rl , Time In Time Out <br /> Business Rep Title O AM I i O AM <br /> } j O <br /> O PM L. i PM <br /> ......_... eP�._...._ Operational Status Tire Type Business Role Storage Type <br /> " ^� " '" Fill one only) Dill all that a' I Fill all that apply) (Fill all that apply) <br /> Tyre Count (#hole"PTE) , �,�� <br /> ( Y) (-� Up Y) ( Pp Y) pY) <br /> O Active Q Passenger Q Generator 0 Oufdoor <br /> O Q Closed Q Altered <br /> GPS Latitude . I Q Hauler Q Indoor <br /> 1 — QInactive 0 Truck <br /> Longitude — Q End-Use Q Container <br /> 9 i Q Planned OTR <br /> Business Type (Fill alt that apply) <br /> j 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> EOS ervice 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 /> -- 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 / FTI / 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 I 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 Q In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments , <br /> 6 <br /> Inspection Form Included: O <br /> Cost?menps Included: 0 <br /> Business Rep's Signature Phone Number 9nspector`s Signature Phone Number <br /> I <br /> INSTRUCTIONS ON BACK Correct:® Incorrect; X 62081� � r :�� ,";� E-' [� , 1 , <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />