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Waste Tire ,oui Bey & Inspection Repwort Inspection Report Number ■ <br /> State B Survey Form - Page 1 <br /> "a CIWMB CaliforniaCa thew 04104) y g I 1 - 1127936 <br /> California Integrated Waste Management Board <br /> Part A-Survey -_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' � LA <br /> O � _ � � Inspection Type (Fill one) <br /> Site Suffix: to Routine Q Re-inspection Q Referral Q Observation <br /> Local �' If Referral,choose referral type(Fill one) <br /> Identifier— Q-o J b l V( n CO'lll nQ CHP O CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address I en �S�0 <br /> a%00 S - E1 floS0A 5}y -- f <br /> Inspection Date <br /> V1 CAj�� Time In Time Out f <br /> Business Rep Title Q AM //�� *AM <br /> ' V <br /> �o � �Q���. -- QPM _ _ - Q- _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 /> 4 Active Q Passenger •Generator Q Outdoor <br /> O Q Closed Q Altered /V A <br /> GPS Latitude Q Hauler I Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned le OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) tQJ h�T <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 O Agriculture Q Shredder I* Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -_ _.... ___- __---_- - <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements j Date m / / m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> it <br /> O Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 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 <br /> �0�1 �10 1 A)F. � 10 _"b,t' <br /> n rN S C s <br /> Inspection Form Inc <br /> luded: O <br /> Comments In luded: <br /> 5M <br /> Bu S2 <br /> i nature Phone Number Ins e�Signtm�eoA( <br /> )thone <br /> Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ' N l �` '��,j� dd ' 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: © ■ <br />