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II Waste Tire Sur, f & Inspection Report spection Report Number <br /> State CIWMB California I 1 - 114 0 8 7 2 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> Califomla Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - + Inspection Type (Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ^ - 1J_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1�+►' � Inspected By Inspector <br /> i C <br /> Physical Address 7 - •`- _/_ � {�Y,vv <br /> Inspection Date <br /> S <br /> g t�C��OY\-, , � Time In Time Out <br /> Business Rep Title ®AM AM <br /> U � ® � PM � � � � O PM <br /> Ske/�/C� 4-bm n mss;S - - <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 ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 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 /> Government Dismantler New Tire Dealer Q Auto Repair Q Trucking Fleet 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 ® Other awe' f ee T <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A !HAULING AND MANIFEST REQUIREMENTS....... Q Notice Of Violation Q Extension <br /> — - --- ----- -- - <br /> Q 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 Vehicle100,1�1'j <br /> Q O 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 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 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 f In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments f <br /> J P10, WC4-s V1o�t� `. <br /> Inspection Form Included: Q2 3 <br /> Comments Included: Il y68 0(o <br /> Business Rep's Signature Phone Number '"I-nspector's Signature Phone Number <br /> — — <br /> IE <br /> INSTRUCTIONS ON BACK Correct: Incorrect: x ( , 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />