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L[88 <br /> Waste Tire Suo* & Inspection Report ispection Report Number <br /> 18 - State CIWMB California 1 - 11413 2 0 <br /> grated 1(New <br /> Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile j Inspection Details <br /> TPID- Inspection <br /> J ` 3 ,7 -� I® TypeQpection (Fill one) Q <br /> Site Suffix: - ©`/ lr.'1 Routine Re-inspection Referral Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: �r ! (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� Inspected By Inspector ' <br /> n G'he�lrole4- � <br /> Physical - � l Q,��� � I�� <br /> Address �tUll�CJI� �-�C. <br /> I z kQ S. c ,ero�ie� L_Y) <br /> l � �t,L Inspection Date / �`� � Q � � � CJ <br /> `!o Time In L (/ Time Out 6 <br /> BusineesssnRep y Title /,� I r 0 AM 0 AM <br /> 5VC <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)j <br /> 40 Active ® Passenger 40 Generator ® Outdoor <br /> - - -- - - ---- --p Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> Q 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 0 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 /> Y A HAULING ANIS 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 /> 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <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 '0 Referred/CIWMB Enforcement <br /> Q Q 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 Other: § - - - - <br /> Comments Q OL C � � ` <br /> - <br /> �a�� <br /> Inspection Form Included: Q <br /> _.3 -� _ <br /> 7 <br /> Comments Included: -_=-- A9 _- <br /> - Busine s Rep's Signature Phone Number In ct 's ignature Phone Number <br /> INSTRUCTIONS ON BACK E ,=;X MI P I L I 62081 <br /> White Co 9114 <br /> Yellow Copy:Operator Pink Copy:LEA <br />