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r= Waste Tire Suo ✓v - & Inspection Report )ection Report Number <br /> State B California Il - 1127862 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 3 1 Inspection Type (Fill one) - - - <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB O Complaint Q Educational Visit O Other <br /> Business or Facility Name Inspected B - — <br /> P y Inspector <br /> )�C7P�r�S A& sti/C{s <br /> Physical Ad ss <br /> Ys-o /V, /"�u C icy r <br /> Inspection Date C <br /> `rte cz CA ?G <br /> Time In Time Out <br /> Business Rep Title o O AM Q AM <br /> v ' ® PM / 7 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 6. o <br /> (Fill one only) (Fill all that <br /> ( apply) (Fill all that apply) (Fill all that apply) <br /> f `" v ® Active ® Passenger ®Generator ® Outdoor <br /> O Q Closed O Altered <br /> G�$ Latitude Q Hauler 0 Indoor - <br /> O Q Inactive Truck <br /> Longitude — Q Planned ® OTR 0 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 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -V A HAULING <br /> RULI�GAND MANIFEST REQUIREMENTS <br /> ------ 0 Notice Of Violation Q Extension <br /> 0 Q § WasteTire Hauler Re9stratadrans ort 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 /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / / m <br /> 0 O 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 <br /> (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 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� 4C_,. <br /> '�.� lc-.t-�- T� — <br /> 4- 444,7 - - - -- - <br /> Inspection Form Included: Q / ) <br /> Comments Included: � 7&4 <br /> Businre Phone Number spector's Signature Phone Number. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X /;' ?e 2131 62081 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy L A <br />