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«3_ �pection Report Number <br /> Waste Tire Sui y & Inspection Report <br /> State of California <br /> CIWMB <br /> Waste <br /> eManag) Survey Form - Page 1 1 5 1 0 7 9 8 8 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L/ / Inspection Type (Fill one) <br /> Site Suffix: ! 7 b/ s- p 0 Routine Q Re-inspection Q Referral Q Observation <br /> 1 <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: •lam ol/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - -- _ <br /> Business or Facility Name Inspected By Inspector <br /> / 61 'S /�e elle 41012-'l 11*7-4 Z >9 <br /> Physical Address 3 � / n? � �fu��g7-A-'l4V,.19 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title * AM AM <br /> 0 PM t/ � 3 � 0 PM <br /> - -- - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) J, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L11� ®Active # Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer * 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 I_ A I HAULING AND MANIFEST REQUIREMENTS 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 /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 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 /> - - -- . - _- ------ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations <br /> O O Other: § <br /> Comments 11-2 <br /> 41,'11,,'< 1�e_e <br /> Inspection Form Included: Q /' ? <br /> Comments Included: <br /> Bu mess Rep's gnature Phone Number/ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK FCort <br /> ncorrect: t ,• I p 62081 <br /> AaWhite Copy: Yellow Copy:Operator Pink Copy:LEA <br />