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Waste Tire S"Y Inspection Re& Ins or nspection Report Number <br /> ■ ' rII p <br /> State CIWMB California 11 - 1127667 <br /> grated asteManage 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 /> TPID- + _ Qnspection Type ( on <br /> Site Suffix: � Routine Re-inspection0Q Referral <br /> Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: 6cu G Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �j�ISs L(Xyl� 3 r <br /> Physlca A dress � - � O � �f��» �•m <br /> 61) . Mile- <br /> C, Inspection Date / 7 <br /> Time In Time Out <br /> Business Rep Title J 0 AM C� �Q Q AM <br /> ® PM 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 /> a Active ® Passenger ® Generator o Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 19 Truck <br /> Longitude - Q Planned ® 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _._ <br /> V A J 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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 Q 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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> o A`v1 � �- Cc�e�'•'� <br /> Inspection Form Included: Q 7 <br /> ��y. �l 1 <br /> Comments Included: Q - (� — -- -- D <br /> Business p's 1gnature Phone Number Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:o incorrect: ( A M 1 2 s2081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />