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A Waste Tire c _y & Inspection ReporOnspection Report Number <br /> ka <br /> State ofCalifornia <br /> Cgrated 1(New04104) Survey Form - Page 1 I - 1141223 <br /> California Integrated Waste Management Board ....._-.......... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ultte"Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) { <br /> Site Suffix�LtH 13 ! 'S' 1 6 1L/ _0L o Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �C / If Referral,choose referral type(Fill one) <br /> Identifier: �GC�C li 1�'1 ( Gt ) iv <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address` - <br /> (........... <br /> S"�_......1...�r.. <br /> !eai <br /> ---. ...i,_ �_....- .............--._.. 1 <br /> Inspection Date <br /> I.-a I - L• Y-) <br /> City State ZIP CodT.... <br /> e Time In Time Out <br /> 1j] <br /> Business Rep Title O AM J AM <br /> O PM ! ' C? ' O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ) <br /> C) Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed D Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 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 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder @ 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 /> - - 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 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 (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 0 In Compliance - No Violations <br /> 0 0 Other: <br /> Comments 1 ` <br /> uz <br /> Inspection Form Included: 0 <br /> Comments Included: 0, <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> A 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � P i3 <br /> �_.;.. a <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />