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Waste Tire Afty & Inspection Repo* Inspection Report Number ■ <br /> ■ 111 State of California T 1 <br /> California Integrated Waste Management Board Survey Form - Page 1 y i 1140785 <br /> p-4rt A- Survey__ _ _ -_ _ BLUE OR BLACK INK PEN <br /> ;iness Profile Inspection Details <br /> ?ID- + O r1 Inspection Type (Fill one) <br /> Site Suffix: ` 11 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIs �- If Referral,choose referral type(Fill one) <br /> Identifier: (,e J 01W T-, (C) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` <br /> L Inspected By Inspector <br /> LINT t lj Q l <br /> Physical Address ' J t�S 3 I — ( V/� I 6s, <br /> Inspection Date ` a / I 6 <br /> �Ca(� 1►q1' `1 Time In Time Out <br /> Business Rep J Title ej C 0 O AM O AM <br /> �A Tlt Com. T(1 I 0 J v PM i l V PM <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 /> f f 0 Active ® Passenger •Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler e 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 /> New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 0 Notice Of Violation 0 Extension <br /> 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 /> 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 In Compliance - No Violations <br /> 0 Q Other: § l __ <br /> Comments <br /> ,pection Form Included: "I� - <br /> Comments Included: �� �o9J�Ipg �r7$ <br /> --- -- <br /> usln eWignatu P ne Number _Insp�r'sSignat <br /> ure Phone Number <br /> INSTRUCTIONS ON BACK C (. E;Correct: Incorrect: V! } A, Jr� ' T Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />