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Waste Tire S, .y & Inspection Report nspection Report Number <br /> �:SII�3 State of California <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 I 1 - 114119 5 <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: , —' 1 j - cl I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ---���--- \ If Referral,choose referral type(Fill one) <br /> Identifier: �Gc Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> c t i f ti C <br /> 44�� _ i_ I <br /> Physical Address ri 11 J 1� 3 <br /> _,- 1__�___I_.�.......... .:...._...... . . .. _............._ z .-............_..._....__....----.T__.._.1 <br /> �trc,Ft Inspection Date i C <br /> t <br /> Cray Sj,ts ZipCO(Ic- Time In Time Out <br /> Business Re .. ... ...- _. _ ..._. .......... , <br /> B p Title O AM I Q AM <br /> ` �— jl _....... Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> fire Count�1Nhote l ) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> LLM <br /> D Q Closed Q Altered <br /> GPS Latitude i ; �' ? Q Hauler Q Indoor <br /> ....__�, -- _..) O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - ---- -- 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Other: <br /> Comments N,L{0),c { r 11SL)PC l' �. f !1,e <br /> r� `_��� <br /> �c <br /> C',Cu �i <br /> Q �1 <br /> ' f <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X J�, V E X A M;P L��� 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />