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Waste Tire SuleY p Reporo Inspection Re ort Inspection Report Number <br /> State B California Il - 1088224 <br /> Cgrated Waste <br /> eManag) 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- C LI / I �/ - /1 / Inspection Type (Fill one) - - -- <br /> Site Suffix: C� ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S„ / �� / (f, ,�JL 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address i - 1 C t OA <br /> Street <br /> `j� Inspection Date ( �� (� c <br /> State ZIP Code Time In Time Out _ <br /> Business Rep Title 0 AM 0 AM <br /> [TJ O PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / �i (Fill one only) (Fill all that apply)'i (Fill all that apply) (Fill all that apply) <br /> f I) Active 0 Passenger Q Generator 0 Outdoor <br /> O 0 Closed 0 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 (T 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 Q Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I 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 <br /> T / 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 0 In Compliance - No Violations <br /> 0 0 Other: § _ <br /> Comments ) 1 ! <br /> V 1A , 0^L_ oma^ —( a�)Cf <br /> Inspection Form Included: 0 " <br /> _ _ r <br /> Comments Included: 0 Business Rep's Signature Phone Number Ins f —�c 1/ ] ? <br /> p' g Inspector's Signature Phone Number <br /> _ - P L F __ ----• --� S 3 <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* <br /> X �Incorrect: � f � A �"d� _� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />