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Inspection Report Number <br /> Waste Tire SL �ey & Inspection Repor. <br /> `= .� State CIWMB California 11 - 112 7 4 9 5 <br /> grated 1steManag) Survey Form - Page 1 <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: 9 6 6 5 1 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local ^n If Referral,choose referral type(Fill one) <br /> Identifier: �� C�//G Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ,L-, f c �L<S <br /> Physical Address 99 — t C) <br /> Inspection Date <br /> Time In 1 Time Out( <br /> Business Rep Title O AMO AM <br /> le PM _2 ® 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 /> (� ®Active ® Passenger 40 Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS Q Hauler i ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR U End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 40 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 /> p y <br /> ENFORCEET US <br /> MNSTAT <br /> Part B- Ins Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility �__ _ _HAU <br /> VA LING ANMANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§ D HaulerRegistrationand Transport of Tires <br /> Q U PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q U PRC§42956-Registration/Decal in Vehicle <br /> Q U 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <br /> Q U 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q U 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q U 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q U 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q U 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q U 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> U 0 1 Other: § <br /> Comments <br /> Alo V i cb l a47_�i ,3 -X ��I)j <br /> Inspection Form Included: Q Z�Q� <br /> Comments Included: Q <br /> Business 's Signature Phone umber ns or' <br /> Nnature Phone Number <br /> INSTRUCTIONS ON BACK LCor ct: Incorrect: i. 62081 <br /> ■ White Cop 'Cl <br /> Yellow Copy:Operator Pink Copy:LEA <br />