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�-' Waste Tire S ey & Inspection Reporo Inspection Report Number <br /> kaCIWMB <br /> State of California <br /> grated Waste <br /> eManag4) Survey Form - Page 1 I 1 - 11413 31 <br /> California Integrated Waste Management Board <br /> Part A-Surv_fes_ BLUE_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' j � � - � Inspection Type (Fill one) <br /> Site Suffix: 11 I <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: �a� 1 ' r CHP CIWMB Complaint_ J � � \���� 0 0 0 P 0 Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B Inspector <br /> To� P Y <br /> Physical Address 1 V 3 I 0 I & <br /> \ Rill <br /> Inspection Date <br /> CA 25iqu t o / 0 Co l O q <br /> Time In Time Out <br /> Business Rep Title � � 5 S0 AM 0 AM <br /> PM � go <br /> � PM <br /> Tau ill � I Pecs' f <br /> y Operational Status Tire Type Business Rol�torage Type <br /> O (Fill <br /> (Fill one only) (Fill all that apply) all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) f � <br /> 4@ Active S Passenger 0 Generator ® Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude 0 Hauler I® Indoor <br /> O Q 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 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler Q Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS <br /> __ ............_. -- <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date [T] <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 (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 <br /> In Compliance - No Violations <br /> 1010 Other: § j <br /> Comments ke S <br /> ] ) ' 1 s <br /> Oo I (�•r(1 ` <br /> Inspection Form Included: 0 4Phone <br /> — �Comments Included: 0 -Busines s Si nature umber Insp or's Signature . Phone Number <br /> INSTRUCTIONS ON BAC Corr ct: Incorrect: X "�' �/! X A P 1 L I El 1112 62081 <br /> White Copy: IW Yellow Copy.Operator Pink Copy:LEA , <br />