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Waste Tire Su ay & Inspection Reporf Inspection Report Number <br /> State CIWMB California I 1 - 11412 6 7 <br /> grated 1(New <br /> Manage) 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- O 6 _ <br /> Site Suffix: c %l! O Inspection Type (Fill one) <br /> j Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J�� �t.1/► l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r <br /> Physlca Addre s <br /> 1�5 l - --- <br /> q _ Inspection Date / l 0 0--1 <br /> Time In Time Out <br /> B/us�iness Rep 1 Title '\ Iq <br /> 0 AM ®AM <br /> 0 PM 0 PM <br /> v Operational Status Tire Type I Business Role Storage Type <br /> Tire Count (Whole/PTE) ' J O (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> 0 Active Passenger Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck I <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> WINew Tire Dealer Q 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 /> _. - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ` Q Notice Of Violation Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / LSI / 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/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 <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> A0 1_16/ccb2w_� Cy- <br /> Inspection Form Included: QI 1 C� / <br /> Comments Included - - �& - - �� <br /> u.sines ep's Signature �l h� ;untberr� Ins r' S• natuirePhone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X DE X A P i L(EI j T 1 _( 62081 <br /> White i;,)py.CI'v+'f^..1 Yellow Copy.Operator Pink Copy:LEA <br />