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-�. <br /> Waste Tire A*y & Inspection Repoonspection Report Number <br /> �« State of California I 1 - 1143985 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <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: ' - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r :\)�Vp IY1 ccun 1L( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C�er►��r � _ o C <br /> Physical Address /�.� I l �✓ ` m 6, <br /> Inspection Date % C) 4-1l p C) <br /> LoAh y-0 �� q-5-3-3E)q-5-3-3E) l e [ L/ <br /> Time In Time Out <br /> Business Rep Title 1 ' *AM i ~ O AM <br /> ­r l r l © D O PM ( 7 O PM <br /> - _ --- ( apply) Business Role Storage Type <br /> ( <br /> -- � <br /> Operational Status Tire Type <br /> Fill one only) Fill all that a I (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) j�` <br /> X./ Q Active Q Passenger ® Generator Q Outdoor <br /> P$ Latitude O ® Closed Q Altered � <br /> �I <br /> GQ Inactive TruckQ Hauler Q Indoor <br /> O <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 0 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 /> _.. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 <br /> 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 E>M <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 j <br /> i <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 1010 Other: § <br /> Comments <br /> p . �__- --- ----' .'`7 -cam 5 - (ignature--- �_-Y�� - <br /> Ins ection Form Included: Q <br /> Comments Included. I®� <br /> Buss Rep's Signature Phone Number In o s Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect XlX . 7Z� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />