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l= � Waste Tire S4^ & Inspection Repo�spection Report Number <br /> State B California Il - 1141349 <br /> CIWMB Waste <br /> eManag ) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> art A- Survey BLUE OR BLACK INK PEN <br /> iusiness Profile Inspection Details 1 <br /> rPID- Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� / If Referral,choose referral type(Fill one) <br /> Identifier: \� CC1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physica Address — j <br /> Inspection Date <br /> JA+Z�Y1 Cit q_c? _ C l✓ <br /> Time In Time Out <br /> Business Rep Title f 0 AM 0 AM <br /> l Z Q a PM 5 Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ®Generator i® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 <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 ED / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q j 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days j (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 i CIWMB 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 /> I 49 In Compliance - No Violations <br /> Q Q Other: § L - - <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> usiness Rep's S' Phone Number In ct Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:O Incorrect: X "I" A)M.P! � E1TIT2 3 62081 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />