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Waste Tire Su. . ay & Inspection Report Inspection Report Number ■ <br /> `" <br /> ICIWMB California <br /> Survey Form Page 1 I 1 - 1143459 <br /> California Integrated Waste Management Board Y - g <br /> Part A- Survey _ - -- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r� Q - ' Inspection Type (Fill one) <br /> Site Suffix: J- l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local `— If Referral,choose referral type(Fill one) <br /> Identifier: S!�Y� J�'11A �LIi1 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> EC13c10c<N TQ S - Q <br /> Physical Address l �en CS <br /> �In S - C bl o Y a.J o S-t, m <br /> S-�0(_► +0 c1 C A �S203 Inspection Date X I C) <br /> Time In v Time Out <br /> Business Rep TitleO O ANI O AM <br /> Saul � � PM � PM <br /> - ---- --- --- ---- ----- Operational Status Tire-Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f �(J Q Active 0 Passenger 40 Generator Outdoor <br /> O • Closed Q Altered <br /> GPS Latitude 0 Hauler S Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 1 New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - --- - — ------ ----- ---- --- <br /> q HAULING§ AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O O PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> OO 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 10 In Compliance - No Violations <br /> O O Other: §Comments u (t0 LAI► , 7I` � *)Ix <br /> - <br /> ��j�I iO`W��o nc �S ��u.t S 0�' t✓U.nc�dl, <br /> Inspection Form Included: Q <br /> Comments Included: - -- - — - - <br /> Business Rep's Signature Phone Number Inspec 's Signatu P one Number <br /> - -- - -- --. -- /' <br /> — — - -- - <br /> INSTRUCTIONS ON BACK i Correct Incorrect: i X� � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :L ® ■ <br />