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Waste Tire Sul&y & Inspection Repor4_ Inspection Report Number <br /> Lai State CIWMB California 1 1 10 8 8 3 7 8 <br /> •� grated asteMana a Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ _ BLUE OR BLACKINK PEN <br /> Business Profile. Inspection Details <br /> -- - - <br /> ---- <br />} TPID- I I f Inspection Type (Fill one) <br /> Site Suffix: �; ( ( C l j <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: f�f j ,t , Y. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> d o <br /> JA <br /> Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I r 1 / l C 0 PM 0 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 /> @ Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • — Q Hauler Q Indoor <br /> p Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® 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 /> O 0 <br /> 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / M <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 0 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities - <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: §. _ ---- --- <br /> Comments <br /> C�(,ti /✓1 C ( < / -/ t ' <br /> ri1 r( i .� .. l �✓,t ��; <br /> f <br /> � ►�� c 0r-� S Yl tj <br /> Inspection Form Included <br /> Q f <br /> Comments Included: Business Rep's Signature Phone Number Inspector's Signature Phone hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 'i E X I,a �i� LiE, II � I� <br /> 62081 <br /> l <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />