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Waste Tire Su, y & Inspection Report inspection Report Number <br /> iEt^ State of California <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 I 1 - 1140697 <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: S (o y T y 6 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��, C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other . <br /> Business or Facility Name Inspected By Inspector <br /> I / <br /> Physical Address 3 — O <br /> Inspection Date C) ® t <br /> Time In Time Out <br /> Business Rep Title / O AM O AM <br /> d ! S � I® PM O Z � � QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active • Passenger ® Generator Q Outdoor <br /> Latitude C Q Closed Q Altered <br /> GPS Q Hauler i Q Indoor <br /> D 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 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 ® Other -� S,rp)�.�. <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS <br /> - --- - Q Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O 1 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 j 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 /> -- <br /> Inspection Form Included: Q �( <br /> Comments Included: 265 qG �U` 3 <br /> ®'Busines _ ep's Signa ure one Number pector's Sign ure Phone Number <br /> INSTRUCTIONS ON BACK 3 62081 <br /> Correct: Incorrect: x !d=X A � P E 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: EA <br />