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;i Waste Tire 54.. vey & Inspection Repoli _ Inspection Report Number ■ <br /> State B California Il - 1127925 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-- _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- //'�� `j Inspection Type (Fill one) <br /> Site Suffix: l 3 V 6 ` - Q I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: — q� U\ �1` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _-_ t� Inspected By Inspector <br /> Physicai'Ad7re��� r <br /> < < AQP&- <br /> �"` <br /> Inspection Date � � <br /> S5D�� v� GA q&;i � V '�Time In Time Out <br /> Business Rep Title O AM O AM <br /> 40 PM a 2PM <br /> rlao br Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l✓ <br /> f ' ®Active ® Passenger Generator Outdoor <br /> O Q Closed Q Altered i <br /> GPS Latitude Q Hauler Q Indoor <br /> O 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 /> 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 r ENFORCEMENT STATUS <br /> j VA HAULING AND MANIFEST REQUIREMENTS <br /> j 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 / 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 E>M <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 I 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 1 Q 1 Other: § <br /> Comments <br /> Com rn Cq-IS R <br /> Inspection Form Included: Q G <br /> Comments Included: ® - ` �-`- - � 6 ��67� <br /> - — <br /> Bu ep's re Phone Number _Ins is S' na e_ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect i C' 1 `}( � ! 62081 <br /> _ _ Z�._J__! <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop : © 0 <br />