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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 3 5 7 3 <br /> grated Waste <br /> eManagei Survey Form - Page 1 <br /> CalifomialntegratedWasteManagementBoard <br /> A- BLUE OR BLACK INK PEN <br /> Survey - - <br /> iness Profile Inspection Details <br /> TPISite - 1, ' 1 O - o InspectionRoutine <br /> Type (Fill-insp Q Q <br /> Site Suffix: t� "� Routine Re-inspection Referral Observation <br /> I LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sal) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �'-_X(_C_\ <br /> Physical Address <br /> `►A 51-�. Vro n�V'\sc <br /> Q Inspection Date <br /> S}o v�rik o n CA SaIS 1 III <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> S 6 PM � 15 � 0 PM <br /> - <br /> - -- - - - - - ---— - Operational Status Tire Type Business Role t Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> Q Active Q Passenger •Generator Q Outdoor <br /> O * Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - End-Use Q Container <br /> Q Planned ® OTR <br /> ,iness Type (Fill all that apply) For `1 <br /> qew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> lJ Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder S Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> I I Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q 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 /> Q Q 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/CIWMB Enforcement <br /> Q Lo 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 In Compliance No Violations <br /> QOther: § j <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: -- <br /> i ss Rep's Signature Phone Number Inspe or's Signature Phone Number] <br /> - — — <br /> • "Y ����� 62081 <br /> INSTRUCTION N BACK Correct: Incorrect 1' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />