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�= Waste Tire SL*ey & Inspection Repor* Inspection Report Number ■ <br /> State B California 11 1127475 <br /> Cgrated 1(New <br /> Manage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey <br /> _ BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5 I 0 Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � � `>C� ��� Q CHP 0 CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> _ � Inspected By Inspector <br /> ►Yl C,l'1�` l o. C <br /> Physical Address <br /> Me 4 <br /> Inspection Date <br /> �it(6- A Ccvl , Ccs G5 1 l <br /> Time In Timeme Out <br /> Business Rep Title O AM O AM <br /> ' • PM L [ 0 PM <br /> G�<<co�CI �t rel <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> •Active Q Passenger • Generator I* Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive .Truck <br /> Longitude — Q End Use Q Container <br /> Q Planned 10 OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS !^ Q Notice Of Violation 0 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 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 /> 1010 1 Other: § - <br /> Comments <br /> Inspection Form Included: Q ' I <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number In r' Signature Phone Number <br /> — q p � _ I 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � J <br /> L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:L ® ■ <br />