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Inspection Report Number <br /> Waste Tire Sfty & Inspection Repoi <br /> �TiStZYf State of California <br /> Cgrated 1 teManag ) Survey Form - Page 1 I 1 - 1141324 <br /> California Integrated Waste Management Board -. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix �-] ttvn Vt1 I - <br /> ,_- a 1 �j� I i 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �, '^� ��U(1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> _ l VLA ���U1�ti:�(1� ! _Y <br /> �. _ t <br /> Physical A dressi 3 <br /> _. .cn ( c , <br /> ..................... .................... - - - <br /> Street <br /> Inspection Date <br /> ._.. ._. l_ .._......_... _....._._._...._� <br /> Time In Time Out <br /> prat ZIP Code <br /> Business Rep TitleQ AM _...._..___...__ <br /> � Ia � � _1 oA <br /> M <br /> O PM QPM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> TITS Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> yx �( <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 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 /> 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 m / 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 /> 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 /> 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> 1 !1t�yifr�r� <br /> Inspection Form Included: 0 - ; <br /> Comments Included: 0 Business Rep's Signature /` Phone Number Inspector's Signature Phone Number <br /> • <br /> INSTRUCTIONS ON BACK rCorrect ' Incorrect: X � \/ LL- X i A M,'r' L E: 1 , 2 {� 62081 <br /> Whi e Copy Yellow Copy:Operator Pink Copy:LEA <br />