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Waste Tire Suit - _y & Inspection Report nspection Report Number ■ <br /> State of 81California <br /> Survey Form - Page 1 ! $ - 0 7 9 4 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J Inspection Type (Fill one) <br /> Site Suffix: I O r 6 J 1 Q ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �fY,/+, �� C001, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> j o <br /> Physical Address � A t <br /> 6 L'5 D.- buCU(.J e"t-�:e_C couf -- <br /> A. <br /> a —7 Inspection Date ' � � � f <br /> Time In Time Out 1 <br /> Business Rep Title O ANI /f ®M AM <br /> PM ".lPM <br /> O i< '�clrY►��r trz�Cv � 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 /> ®Active ® Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler I* Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned 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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <br /> M / M / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> 0 0 Other: § --- ------- <br /> Comments <br /> see <br /> Inspection Form �nc <br /> ncluded: Q <br /> Comments luded: <br /> Business Rep's Signature Phone Number Ise r' Si at re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ('k" 11E 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink CbA1 <br /> ® . <br />