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Waste Tire SL_ . ay & Inspection Report` Inspection Report Number ■ <br /> State B California I - 1143849 <br /> CIWM grated 1st(New <br /> Manage) Survey Form - Paige 1 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � _ Q ' Inspection Type (Fill one) <br /> Site Suffix: i® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type Fill one <br /> Identifier. ' Ct })'yl �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName Inspected By Inspector <br /> Physical AddresslS <br /> c L 1 Qr-) <br /> Inspection Date cad © �( <br /> Time In Time Out <br /> Business Rep Title O AM j ] O AM <br /> shco iron_ C2 3 ® PM � C L O 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 /> ® Active 0 Passenger ® Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> D Q Inactive 16 Truck 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 0 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 <br /> 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. j 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 /> 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 f CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I <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 r1 , fZXv" <br /> I <br /> Alp c)r Ar?oo r) <br /> Inspection Form Included: Q i <br /> Comments Included: Q �+-R -- 73 — <br /> Busin ss Rep's Signature U Phone Number s frS gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct.0 Incorrect X 1 213 62081 <br /> ■ White Copy:CIWM6 Yellow Copy:Operator Pink py:LE ■ <br />