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Waste Tire Sur y & Inspection Report Inspection Report Number <br /> is <br /> State B California I 1 - 11413 01 <br /> Cgrated Waste <br /> 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- / y ,_7 _ Q Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /7 If Referral,choose referral type(Fill one) <br /> Identifier: C,Drc 7j [- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 q <br /> 13 <br /> Inspection Date � � � 19 g <br /> Time In Time Out <br /> Business Rep Title ® AM n AM <br /> y 0 O O PM (% S' 0 PM <br /> - 0- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) _70 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> Latitude C 0 Closed I 0 Altered <br /> CIPS i 0 Hauler 0 Indoor <br /> O 0 Inactive j I* Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler ® Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or ERCT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 0 1 0 Other: § - <br /> Comments <br /> � V-e.,^I a°ay <br /> rae."��� 1,�� �%'a�..GQe 1' � ✓'�u�✓d r c.v� �'v*.� '" 1�L �1` Ui''�,.P� <br /> Inspection Form Included: ( ?-0� <br /> Comments Included: 0 - -- - -- ----------- -� - ---- -- — - -; <br /> -- -_-Business Re's Signature Phone Numbers Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Cor ect: ncorrect: X :";" IE X A , J�JEJ-1112N 62081 <br /> White Copy: W Yellow Copy:Operator Pink Copy:LEA <br />