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Waste "ire 4 & Inspection Rep( Inspection Report Number <br /> lif( State of CaliforniaCIWMB <br /> T 1 <br /> California Inegrat d,81 Was eeManagelment Board Survey Form - Page 1 I l 1127550 <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> Ste Suffix: (�1. - Inspection Type (Fill one) - <br /> t v ' © 0 Routine ®Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: `� V` 1 ( tvt, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - -- <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address `� '"� Z [iyc W► <br /> ISLI5 H (ICY, A-VC- <br /> Inspection Date <br /> V Time In l V Time Outl �J <br /> Business Rep Title 0 AM / 0 �AM <br /> D O PM l V O PM <br /> - Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Z 0 ® Active ® Passenger ® Generator ®Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill 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 CI�c L Pads <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 0 I,PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 ExtensionI <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 /> .......... <br /> 0 0 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/CIWMB Enforcement <br /> 00 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 0 inf!Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> - -- � e- - Com - <br /> Ioru <br /> Inspection Form Included: C �- <br /> Ds� / -- - ,cam--y CJ 7 <br /> Comments Included: ® - - - --� -"VQG-p z�. -�7 -- - <br /> Susi ss ep s i nature Phone Number In r Si nature Phone Number <br /> T ;,t Incorrect: 'i - _-- -- - ' <br /> � ; <br /> i <br /> '.NSTRUCTlS�NS O BACK - 62oN <br /> A r y 'l oior PinK Cop%r;--A <br />