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°= Waste Tire S _ ey & Inspection Repa Inspection Report Number <br /> State of California I 1 1127708 <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 1 <br /> TPID- L Inspection Type (Fill one) <br /> Site Suffix: I O 6 l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: iJ (gym Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> j 4o <br /> Inspection Date 1 /"1 J l <br /> W I _ A_ q5 q� J <br /> Time In Tilme Out <br /> Business Rep Title i CJ O AM i O AM <br /> 'SI 0 PM 1 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 /> C) ® Active ®Passenger ®f Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 46 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 /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)T) <br /> Q O _ - - --- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 In Compliance - No Violations <br /> Q Q 1 Other: § L {� / \� <br /> Comments f�(1LJ��"� t 5 (�C�l 7 � _Pe Y t' C.2 /�� 71h,?, U�t <br /> ,til_ V1 Q- 1 <br /> cY c, <br /> I OE <br /> C'�TY1C�f�/1 <br /> Inspection Form Included: Q <br /> Comments Included: Q — <br /> Busine Rep's Signature Phone Number Ins a or'�S nature Phone Number <br /> - --.__ <br /> INSTRUCTIONS ON BACK �Correct:I, incorrect: J }e* ! L 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co : ® ■ <br />