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Waste Tire Sui . _y & Inspection Report ispection Report Number ■ <br /> CIWMB81California <br /> (New 04104)ment Board SUrVe Form - Page 1 11 - 1143492 <br /> California Integrated Waste Manage <br /> 'art A- Survey y BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 �, L 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cot ,�9 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address -1 l l 4 M-so <br /> Inspection Date -7 <br /> 'i C.� 9 <br /> I Inspection <br /> �/ l <br /> Time In Time Out <br /> Business Rep Title ®AM O AM <br /> 1 1 o O PM i ' 0 PM <br /> ,,j <br /> - - -- - - -- --- -- — - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r ,rte (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 End-Use 0 Container <br /> -- YP (Fill- --..- - - � Planned ® OTR <br /> Business Type all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other � �� � Sc�lej J�1e10�Ljy <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ' A HAULING AND MANIFEST REQUIREMENTS <br /> 0 00 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date IT / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> i <br /> 0 O --- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments <br /> se <br /> ,Inspection Form Included: <br /> Comments Included: <br /> ® Business Rep's Signature Phone Number sp tLE ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X � VI i }f 62081 <br /> White __ ---- _—___------- -- -_ ■ <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink C <br />