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"Vaste Tire Sur . ey & Inspection Report Inspection Report Number <br /> of California Il - 1140822 <br /> Integrated <br /> Waste <br /> 81 eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> rt A- Survey _- - BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> rID- Inspection Type (Fill one) <br /> Site Suffix: b Z I to ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> Physical7�S ddrs <br /> Inspection Date <br /> l rc4lczti t��rry,� C� l T'2 3 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> d e2 ._ L ® PM 0 Lj ® PM <br /> ----- —-- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (r� <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GP$ Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other n f/iv[ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS i <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 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ffl <br /> � Ffl <br /> / 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 ® In Compliance No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> h._,,ection Form Included: 01 <br /> Aw <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number -J speetr7 or's Signature Phone Number, <br /> E A <br /> X / � ill �- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: '/� P L 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />