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® Waste Tire Suity & Inspection Report <br /> Onspection Report Number <br /> State of California - - ■ <br /> CIWMB1819 teManage) Survey Form - Page 1 I 1 - 1088381 <br /> California Integrated Waste Management Board <br /> PartA- Survey <br /> - -- _ —_ - -- -- -_ ._--- BLUE OR BLACK INK PEN_ <br /> - <br /> BusinessProfile. Inspection Details <br /> TPID- r 1 C 1 Inspection Type (Fill one) <br /> Site Suffix: <br /> �. L ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> r? i CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> jj fl <br /> Physical Address <br /> Sfreef <br /> " Inspection Date ( .' LIJ�J —��� <br /> City de <br /> Cif+' Stafe 'ZipCode—' Time In Time Out _ <br /> Business Rep Title , Q AM <br /> , rr, [�7 ® AM <br /> /k <br /> -firJj, /- i. f/7 <br /> PM <br /> 1 <br /> PM <br /> Operational Status! Tire Type Business Role,)y ( . <br /> (Fill.one only) 011athapp, iall that appl <br /> Q'OActivff; Pass engeQ Generator 'S(Ftioll rqaalugl t#dhoaTtpyar0ppep I <br /> � <br /> GPS Latitude OQ� ClosedQ Altered <br /> Q HaulerQ Indoor <br /> -- - Inactive ,'. <br /> Trucf <br /> o Q Q. k :1 <br /> LongitudeQ End-Use O Q Container " <br /> �.� <br /> :Business Type {Fill alt that a�i5(y) ,, <br /> Q New Tire Dealer Q Auto Repair C) 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 Q Agriculture Q Shredder Q Other <br /> _ I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V PRC 42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> O O § g' p <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O O 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 /> - - - <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q 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 O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> r <br /> lrispect'#n Farm Included QI <br /> - O <br /> _– Cornlments.Mcludecl _-- s -, --- ._ d <br /> Ins ect..o.r s"Signature,•;;f.'"1 <br /> Phone Number <br /> Ph n Number , <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: X ,Gk V i_EYj Y1_1 . L`� .fir r �_s G 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA _ ■ <br /> -- _ W <br />