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Waste Tire Aley & Inspection Re o% Inspection Report Number <br /> State CIWMB California I 1 - 114 0 9 5 5 <br /> grated 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- Inspection Type (Fill one) <br /> Site Suffix: O l lb Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SOL J ooa,Lt1n Ci'JQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - 1 0 1 <br /> Physical AdQress E�Jo <br /> vT <br /> � Inspection Date <br /> D <br /> '��C•1L J Time In Time Out tt 111 <br /> Business Rep Title O AMQ AM <br /> U • PM © 5 ® PM <br /> n -------- - - - - <br /> - - - - ----- --- -- - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 ' O [ O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d� J 0 Active 0 Passenger ®Generator * Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 4111 Truck i <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0-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 •Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 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 /> 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 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators if In Compliance - No Violations <br /> Q Q Other: § <br /> i <br /> Comments <br /> co ,43 <br /> I <br /> Inspection Form Included: <br /> rt Comments Included: ® d`f 6 o �y ZSign <br /> B siness Rep's Signature - Phone Number Inspect 's ature Phone Number <br /> -- _ - --- <br /> INSTRUCTIONS ON BACK 1 Correct:* Incorrect X Al �/li X A 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />