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Waste Tire Su 4 & Inspection Report Inspection Report Number <br /> Ifi State CIWMB California I 1 11412 8 5 <br /> grated 1(New 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: I - /''� � <br /> l 9 9 L/ I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� )VI CWit Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � Inspected By Inspector <br /> �(��Uet� l�-u ACLLA) � ) 1r1G, / ) <br /> Physics Address � <br /> r Inspection Date <br /> Time In Time Out <br /> Business Rep Title l Q AM Q AM <br /> es�r PM ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> f * Active Q Passenger ® Generator ® Outdoor <br /> GPS Latitude <br /> Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O ! Q Inactive • Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> —_. - — — - <br /> V� A 1 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 Date m m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years I ', <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 /> 0 ! Q Other: § <br /> Comments-'��d!'-r�Le t .PG�72�'Yt� CCc$�/�'� kf <br /> Inspection Form Included: Qi <br /> Comments Included: Q! 4sc5 Sig re Phone Number s i ature Phone Number j <br /> �.�, 62081 <br /> INSTRUCTIONS ON BACK ip :X fl', 4 P 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />