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Waste Tire Su4W Inspection Report ction Report Number <br /> I® State of California <br /> CWMB <br /> 1steManage) Survey Form - Page 1 I1 - 1127535 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� </ � � � � O f Inspection Type (Fill one) <br /> Site Suffix: `/ Il Q Routine 0 Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> 1n <br /> Identifier: ' 1 ���,((� �-��-! G Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected B <br /> P y Inspector <br /> PO h?C-) /il'�S — <br /> Physical Address <br /> Inspection Date / O <br /> Time In Time Out <br /> Business Rep Title lQ AM / O Q AM <br /> UaG4 sp PM <br /> ___* PM <br /> (Fillone only)lStatus (Fill all that apply) Business Role Storage Type <br /> �i p Tire Type <br /> Tire Count (Whole/PTE) a 5 Oi <br /> (Fill all that apply) (Fill all that apply) <br /> f ®Active ® Passenger ® Generator • Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer O Auto Repair O Trucking Fleet cliGovernment Q Retreader Q Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body O Car Dealer 0 Collection O Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS llNotice of Violation Q Extension <br /> _- - -- __ - ---I <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date <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 EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Other: § <br /> -- <br /> Comments <br /> Inspection Form Included: Oj <br /> Comments Included: - <br /> usine s s Si ure Phone Number Ins t is i ure <br /> -_- -_ _ _ P Phone Number <br /> INSTRUCTIONS ON BACK Corr t Incorrect: X ,. �/ [C x A; p E f 2 3 <br /> 62081 <br /> White Copy: I MB Yellow Copy:Operator Pink Copy:LEA <br />