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Waste Tire Sui .ay & Inspection Report Inspection Report Number <br /> State B California I 1 - 1143611 <br /> CIWMB Waste <br /> eManag) 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- Y _ O Inspection Type (Fill one) <br /> Site Suffix: U Q Routine a Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� 0 CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name �- Inspected By Inspector <br /> Soper - ppcv+ / i 1 _ <br /> Physical AHHdress <br /> c�070 is , <br /> Inspection Date 3 / <br /> Time In Time Out <br /> Business Rep Title O AM ) 0 AM <br /> • O � .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 /> ®Active a Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O <br /> Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> (9 New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> (16 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O 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 <br /> Q Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E>M <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 Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> i <br /> InspectionComments Included: OI <br /> C - - -- - - - ----- --- < <br /> Bu n p Signature Phone Number to nat a Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X (` ✓ ` 1 + 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />