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ay & .Inspection Report Inspection Report Number <br /> Waste Tire Su <br /> State B California I 1- 10883 0 5 <br /> Cgrated asteManag j 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 /> Tplp_ � C > q - � Inspection Type (Fill one) <br /> Site Suffix: ` 3 J I 4PRoutine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q �,(�(� - —� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facili Name <br /> Inspected B <br /> p y Inspector <br /> Ph st a Address <br /> I L-S6t) <br /> Street � <br /> Ul Inspection Date <br /> C tI yy State ZIP Code I Time In ITime Out _ <br /> BusinessRepTitle , 1 ��O AM I —� �I 1 Q AM <br /> ® PM ���—j I 0 PM <br /> -- - -- - == -, ---- —_--- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) 2 (Fill one only) -(Fill all that apply) (Fill all that apply) (Fill-all that apply) <br /> 4 Active Q Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -—�--- • — --- - - 77=—_-- Q Inactive If Truck <br /> Longitude - i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair I* Trucking Fleet Q Government 0 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 I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 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 EX7) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q I Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I C-IWMB 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 <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> CommenAANts - ,�)aS ePI <br /> � x9s <br /> n V4 <br /> Inspection Form Included: Q / ' <br /> Comments Included: Q `/ �`=t <br /> u ' ess Rep's Signature Phone Number Inspec s ignature Phone Numberer- <br /> INSTRUCTIONS ON ACK C rre Incorrect: )( A AA P E ; ] 2 3 62081 <br /> White C py:CI B Yellow Copy:Operator Pink Copy:LEA <br />