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= Waste Tire Su. - Jy & Inspection Report Inspection Report Number <br /> State B California g I 1 - 1143515 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> rBusiness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix- �- - - 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �aY l \C�J t� ��L If Referral,choose referral type(Fill one) <br /> Identifier: J 1 L,'f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LE�CZ) GCA(A&00'b <br /> 39 <br /> Physical Address <br /> Inspection Date U V 1 <br /> ��`Uy ` CA Time In Time Out <br /> Business Rep Title J c O AM 7 O AM <br /> 1 I J O PM 0 0 ® PM <br /> - - ---- ----- ------- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) p o,, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` `� 4D Active ® Passenger ® Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive Truck <br /> Longitude - O Planned Q OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 O Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 EXT) <br /> Q 0 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 10 1 Q Other: § <br /> Comments / �r <br /> Inspection Form Included: Q <br /> - D_�- <br /> Comments Included: <br /> Bus ss Rep's Signature 4he Num_ ber I t.is I at a Phone Number <br /> - - - -� <br /> INSTRUCTIONS ON BACK Correct Incorrect t%�c P 1 3 62081 <br /> N <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co ® ■ <br />