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a <br /> Waste Tire rve & Ins ection Re (T[ Inspection Report Number■ Y p P 0 <br /> State of California I 1 - 1140744 <br /> CIWMB11811 <br /> Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f� � � _ � � Inspection Type (Fill one) i <br /> Site Suffix: (Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: {1 ��4 1. n (61-W+ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business orFacility Name <br /> K1 � 11-- Inspected By Inspector <br /> (nlen(� S <br /> Physical Address <br /> Inspection Date <br /> CA I�Qb <br /> ,U1r,C•� Time In Time Out <br /> Business Rep Title �j 0 AM 0 AM <br /> ' " 0P 3 5 GPM <br /> -- - - - - -- - Operational Status Tire Type i Business Rol <br /> Tire Count(Whole/PTE) e Storage Type <br /> / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I a �p <br /> ®Active Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 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 ® 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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --' <br /> T_ <br /> } A-7 HAULING AND-MANIFEST-REQUIREMENTS ------_---.— __.___ _-- - --- _--v�-- -- <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 Datem / m <br /> 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 /> CommentsI <br /> I W ul r'6L. OI S e, fc 1 S. D f lZs r,l S�( ,—vl <br /> Inspection Form Included: 0i ' <br /> Comments Included: ®; � J <br /> usiness Rep's Signature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK i Correct:* Incorrect + 62081 <br /> _ � / � E AM V <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />