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Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State CIWMB California I 1 114 3 6 0 0 <br /> grated 1(tNew <br /> Manag) 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 /> TPIL'- � � '1 � � � � - Q Inspection Type (Fill one) <br /> Site Suffix: y I A Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: �(9 afiLAi1 C��� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> r- Inspected By Inspector <br /> Physical Address 3 1 ] 1'�(� �Stot 6 <br /> Inspection Date <br /> (A <br /> L Time In Time Out <br /> Business Rep Title f C 0 AM s @ AAM <br /> I e PM PM <br /> -- - -- -n. -- - -- Operational Status Tire Type Bus <br /> Tire Count(Whole/PTE) iness Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> Active ® Passenger 40 Generator (a Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 00 Inactive � Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other Fc�src� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m <br /> 0 : 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 00 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> 0 0 Other: § <br /> CommentsAX—IfJ <br /> 00641 <br /> Inspection Form Included: 0Vnesep's <br /> I' <br /> `�iv't q(,'( 1�j1, dJ`� 178 <br /> Comments Included: ® - <br /> ignature Phone Number Insp or's Signat a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X X ,�; I <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:L A <br />