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pe Waste Tire Sul y & Inspection Report ispection Report Number <br /> State of81(Nen Il — 1140656 <br /> California Integrated'Wast Manage'ment Board Survey Form - Page 1 <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ _ a Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: �� C 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addres <br /> 1 y tom). I0t Z,44z.►- Git,� <br /> Inspection Date <br /> CIS <br /> Time In Time Out <br /> Business Rep Title o ' y <br /> 0 AM Q AM <br /> �+ <br /> � � PM � � 3 � ® PM <br /> 141L <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) > O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS I 0 Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude — O Planned Q OTR O End-Use 410 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other rZo�� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years - <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers � (,:) Refe_rred1CIWM_B Enforcement <br /> Q 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 ® In Compliance - No Violations <br /> Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® -= --- <br /> Bus Hess Rep's Sign-ature Pho a Number nspector' Signat a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr ct: ' correct: X '� Ey XA 3 <br /> White Copy: IW Yellow Copy:Operator Pink C y:L <br />