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Waste Tire Afey & Inspection Repc.- _ - Inspection Report Number <br /> State of California 11 - 1143615 <br /> CIWMB181 <br /> Waste <br /> eManag) 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- a S , - Inspection Type(Fill one) <br /> Site Suffix: aC `� a 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIfIf Referral,choose referral type(Fill one) <br /> Identifier: ✓�� (_� ./ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical ress � ✓�-� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title r (�} ; O AM O AM <br /> QPM � � 0 PM <br /> 1 d <br /> ti cmcu_— cue-4_ f I Al" <br /> d/ <br /> - - - -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 46 Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck I <br /> Longitude - Q End-Use Q Container <br /> Q Planned 1 Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 49 Auto Repair Q Trucking Fleet Q 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 /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I HAULING AND MANIFEST REQUIREMENTS <br /> A <br /> Q A Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport 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 /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / 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 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: 01 n <br /> Comments Included: ���� <br /> ---- ------- <br /> Business Re s Signature Phone Number In a or' Si nature Phone Number <br /> ./ --- <br /> INSTRUCTIONS ON BACK orrect:9 Incorrect: I Ev XI A , , 4 1 j i 2 131 62081 <br /> ■ White .. —- _ _. - -- - - ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy L <br />