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Waste Tire Su: y & Inspection Report nspection Report Number <br /> i� State of California <br /> CIWMB1811 Waste <br /> eManag ) Survey Form - Page 1 Il - 1140602 <br /> California Integrated Waste Management Board <br /> Part A- Survey___- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ -7 Inspection Type (Fill one) <br /> Site Suffix: 3 7 f ) t © ® Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local If 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 Address <br /> �O SD I)Ve- - <br /> 1-J^�� ! Inspection Date / 0 <br /> CA is-33 rJ (® <br /> Time In Time Out <br /> Business Rep Title AM Q AM <br /> 0 PM ` � ! � a PM <br /> paza �ruIla c� Storage Type <br /> - - -- - <br /> Operational Status I Tire Type I Business Role <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t � <br /> 0 Active Q Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered /V/r4 <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 A HAULING AND MANIFEST REQUIREMENTS <br /> I 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 <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 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/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 /> -- a�-- t `c cny%. - <br /> �p``civ✓i�2( G�Lc t l2�� <br /> Inspection Form Included: Qi <br /> 1 OroZ <br /> Comments Included: ® - - `'�-' � - - �C �/ <br /> Business ReN's Signature Phone Number Inspector's Signature Phone Number <br /> - - - - - - - - --------- - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X {) P L i I I 3 62081 <br /> White Copy CIWMB Yellow Copy Operator Pink Co :L <br />