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Waste Tire Su. :y & Inspection Report Inspection Report Number - <br /> @IGdT State of California <br /> California <br /> CWMB Waste <br /> eManag ) Survey Form - Page 1 I1 - 1141295 <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 G 6 - © l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ � If Referral,choose referral type(Fill one) <br /> Identifier: ` �'� (��� CCU/1, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name_ Inspected By Inspector <br /> Physical Address <br /> b <br /> 3E zes <br /> Inspection Date � � � z <br /> C•Gf Time In Time Out <br /> Business Rep Title O AM Q AM <br /> — e Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 Jj <br /> V A HAULING ANMNIFESTRQUIRE Ed 0 Notice Of Violation Q Extension <br /> Q ORAND <br /> Registration 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 <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)(T) <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 f CIWN% Enforcement <br /> O O 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 O Other: § <br /> Comments <br /> V t <br /> fZ�� C3� ��t ©ate<.we e✓ <br /> Inspection Form Included: 011 <br /> eComments Included: �� v Business Rep's Signature Phone Number Ins 's S1 ure Phone Number <br /> INSTRUCTIONS ON BACK 1 Correct: Incorrect , 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA p <br />