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== Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> I1 - 1143973 <br /> 111 State of California <br /> CIWMB Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey -—— -- --- - _ _ --- - - - - - - <br /> Inspection Details <br /> Business Profile i <br /> TPID- �'} I inspection Type (Fill one) <br /> Site Suffix: I v ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: � ;� �1� cG�.vv Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address r 1'Yl61 'tc` <br /> ��(�L� � Inspection Date <br /> A Time In Time Out <br /> AM AM <br /> Business Rep Title <br /> O PM � l � 1, O PM <br /> m6v �+ __--- -_ - =---...------ 4P6 ft--- Operational Status Tire Type ' BusinessRoleStorage Type <br /> (Fill one only) (Fill all that apply) <br /> Fill all that apply) <br /> (Fill all that apply) <br /> Tire Count(Whole/PTE) , pRJ <br /> ® Active Q Passenger ®Generator Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Q End-Use Q Container <br /> Longitude -- - - - — ------Planned - - -®��//.�/ <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 ® Other �y <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I q I HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <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 Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Date M / m / m <br /> Q , Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT} <br /> Q <br /> Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> - - - - - - <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 I 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 Q Other: § -- <br /> Comments <br /> Inspection Form Included: `� <br /> Comments Included: ®IIy.�� _- _ C7� ��---- <br /> Business Rep's Sighature Phone Number In p ctor' gnature - Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E X Mh. i 62081 <br /> - - - - - ® ■ <br /> ■ <br /> Pink Copy: <br /> White Copy:CIWMB Yellow Copy:Operator A <br />