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HE; Waste Tire Su .y & Inspe6tion' Repore Inspection Report Number <br /> State of 181(New - <br /> i <br /> CIWIVIB 1(teManag) Survey Form - Page 1TI1 - 110 8 4 7 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- MW <br /> Inspection Type (Fill one) <br /> Site Suffix: Ll <br /> Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Sa� JQ(��V tn 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility NameInspected By Inspector <br /> Physics Address <br /> Street <br /> Inspection Date <br /> L� � �— Time In Time Out <br /> City � � State Zip C;sr,� <br /> Business Rep Title AM —T <br /> Q� �] I <br /> � AM <br /> e.✓- y---- ` — "— <br /> Operational Status Tire Type Business p yp Hess Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 inactive ® Truck <br /> Longitude — 0 Planned 0 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 L&WCjZ.4.—M F <br /> — <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 <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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments e <br /> Inspection Form Included: 0 - 2a�1 / -66 ` 7 <br /> Comments Included: 0 <br /> Business Rep's §ignatu Phone Number Ins pe' or' ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corect: Incorrect: ( E X Aq P E : !.2 3 <br /> White Cop CIWM Yellow Copy.Operator Pink Copy.LEA <br />