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® Waste Tire Sul&y & Inspection Report Inspection Report Number <br /> 1 <br /> State CIWMB California 1 y 112 7 6 3 3 <br /> grated 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- Inspection Type (Fill one) <br /> Site Suffix: ORoutine ORe-inspection OReferral OObservation <br /> Local i- If Referral,choose referral type(Fill one) <br /> Identifier: y, c 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name L/I Inspected By Inspector <br /> Ac 00e, CLOY" <br /> Physics( Address E-T <br /> (7' .. <br /> .......... <br /> ... <br /> Inspection Date V i <br /> Cl..d_l � ZI, _(J._L_v_3 <br /> i Time In Jj <br /> __. _ <br /> Time <br /> e Out <br /> Business Rep Title 0A <br /> - <br /> Q AM <br /> O PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire 7Ut1 (Vilhale/ 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ; .. <br /> 0 Q Active 0 P ss-nge! 0 Generator 0 Outdoor <br /> ��` 0 0 Closed Afieied <br /> GpS Latitude 0 Hauler 0 Indoor <br /> — __ � Inactive TrGck <br /> -. ._. r 0 <br /> Longitude - i 0 0 End-Use 0 Container <br /> 9 ( Planned 01-R <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 0 Other ,; <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING,AND MANIFEST REQUIREMENTS 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 <br /> M / M 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 <br /> (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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 D In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ,�s✓:(i��1� /f7 � ��'C �/`\ !/'t( C f�F`G� ! f" t"7()�{r i�. . ; : ;,: <br /> ( i n <br /> Kl� <br /> f <br /> Inspection Form Included: <br /> .. - <br /> Comments Included: - - <br /> Bus+ne.ss Rep's Signa°urp Phone Number Inspector's Signature Phone Number 'J <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X /- \/ a A _�� 1 fl <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />