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Ulf <br /> Waste Tire Su ey & Inspection Report Inspection Report Number <br /> » State of California <br /> CIWMB1811st(Now <br /> Manag) Survey Form - Page 1 I 1 - 1141296 <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: I �l i y g - O l <br /> ® Routine 0 Re-inspection Q Referral Q Observation <br /> Local �� ��� Co` If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical Address ( ! l.��j �rn LL►CL <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title OAM 0 AM <br /> ® PM I 02 3 • PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ®Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive ® Truck <br /> Longitude — O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair ® Trucking Fleet Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O Hauler 0 Agriculture Q Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V, A j HAULING AND MANIFEST REQUIREMENTS0 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements f Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O 1 O Other: § J <br /> Comments uil I dyl - ,— <br /> CC ,p <br /> t -S <br /> Inspection Form Included: O <br /> Comments Included: Q _3oz� <br /> s ness Reps Signature Phone Number Ins' or's =Lmh_ Phone Number <br /> - _ -- — <br /> INSTRUCTIONS ON BACK Correct: Incorrect. . � j p62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />