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Waste Tire Sui _ay & Inspection Report Inspection Report Number ■ <br /> WMB 81California <br /> w04104) Survey Form Page 1 I 1 - 1143631 <br /> California Integrated Waste Management Board Y - g <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- k <br /> S ^ - O Inspection Type (Fill one) <br /> Site Suffix: `6 - - 1 O Routine Q Re inspection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: (� u <br /> ID 0.y�1,11� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> L <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> en Es co[G <br /> UA C-F wt <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title (� 2 AM 40 AM <br /> j ' " J O OPM � I � ® QPM <br /> -- - -- - --- - - Urernw� Operational Status Tire Type j Business Role Storage Type <br /> Tire Count(Whole/PTE) 5 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a <br /> ® Active Q Passenger ®Generator Outdoor <br /> Latitude O Q Closed Q Altered j <br /> GPS Q Hauler 40 Indoor <br /> D Q Inactive .Truck <br /> Longitude - Q Planned j Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair *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 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 Q <br /> 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 m / m / m <br /> Q Q .14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 114 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 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q Q Other: § _ <br /> Comments � - <br /> c x`,41 to�p�r_�—per <br /> 1� Uki FG�CI <br /> Inspection Form Included: QI Q G 1�A� ' �{(n{� ,/ <br /> j Comments Included:40ao 1 i �f"�� - 0611 `� " P i <br /> sines n Phone Number_ Inspect 's Signatur Phone Number <br /> - _ <br /> -- - 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect. I E X A P 1 : 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ■ <br />