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■ Waste Tire ou. _ Jy & Inspection Rep,rt Inspection Report Number ■ <br /> State of California 11 — 1143961 <br /> CIWMB181 <br /> Waste <br /> eManage) 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- ' O - © I InspectionType ( on <br /> Site Suffix: JRoutine Re-inspection0O Referral O <br /> Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: Sup l� ��(� C �,� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 5 a Y\ J c, ,�i �)ev e,1(ky, _ <br /> Physical Address 3 q l O ' Re-0 �S ch) <br /> "5 (, Inspection Date j, 1 b <br /> G Time In Time Out <br /> Business Rep Title O AM O AM <br /> \\ t O PM O PM <br /> -- - - --- - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O Active * Passenger ® Generator O Outdoor <br /> Latitude O 0 Closed O Altered N/A <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive � Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 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 /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m , m / m <br /> Q Q 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 /> QO -- - - <br /> � 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 0 Referred/CIWMB Enforcement <br /> 0 Q 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 . In Compliance - No Violations <br /> 0 Q Other: § <br /> Comments ��•s�.. 1� �lc, \ �L,1� �u�►-uL - --���L-II�L-J "�`-�� �- --- <br /> t <br /> Inspection FormIncluded: 01 <br /> Comments Included: ® v�� <br /> 13 iness Rep's Signature Phone Number Inspect Signatu Phone Number <br /> INSTRUCTIONS ON BACK �-Correct:0 Incorrect: i i i � X A P, 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: <br />