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Waste Tire Inspection Report Number <br /> S y & Inspection Repa _ p p -_ <br /> W 7u State CIWMB California T i ® n /q /r <br /> grated Waste <br /> Survey Form - Page 1 1 11 - 1088476 <br /> VX 4 'Y6 <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: ( �� C1 0 Routine Q Re inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address _( ( I l CLlL_ t <br /> Street Inspection Date E.LL= / TF-7fl <br /> City State ZIp Cocle, Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ��^ <br /> Operational Status Tire Type 1 Business Role Storage Type <br /> t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l i1 <br /> ® Active Q Passenger Generator Q Outdoor <br /> f .. � � Closed Q Altered <br /> PS Latitude Q Hauler p <br /> Indoor�� O^- � __ — <br /> Q Inactive Q Truck <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 Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body @ 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 i 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 /> 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 m m m <br /> 0 ' 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> § P P g y (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR 18459.2.1 -Submittal of Comprehensive Tri Logs within 90 days <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 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 in Compliance No Violations <br /> Q Q Other: § - <br /> Comments Il <br /> c 1 - _ <br /> C <br /> Inspection Form Included: Q. <br /> Comments Included: Q - ----- - _ <br /> ,Business Rep's Signature Phone Number Inspector's Signature ( (r Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X Ak XIA MIPILI <br /> 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:L�A <br /> ,t <br />