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� = <br /> Waste Tire Sur, j & Inspection Report spection Report Number <br /> Slate B California I - 1127863 <br /> =MB Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A_Survey__._- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details J <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r y2 S Lf j ® Routine Q Re-inspection Q Referral Q Observation <br /> i <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 Inspected B <br /> P y Inspector <br /> Physical Address O t � Y� <br /> Inspection Date <br /> rze e'v C�� �/ 3 n y <br /> Time In Time Out <br /> Business Rep Title % ® AM Q AM <br /> _�_ 0 P .2 u r� 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 /> i <br /> ® Active Q Passenger le Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude – Q Planned 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 f <br /> I V A HAULING AND MANIFEST REQUIREMENTS Q <br /> __ —. _. _- - Notice Of Violation Q Extension <br /> Q 1 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 <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 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 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 <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Bus nes Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect �'�,. <br /> V e )f .A M. – 1 2 3 62081 <br /> - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy L <br />