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■ it Waste Tire Suh - .:y & Inspection Repori nspection Report Number ■ <br /> «= State CIWMB California I 1 - 114 3 9 81 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> r 'A-Survey -BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> Ip- Inspection Type (Fill one) <br /> Site Suffix: I C) ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ��� t/\� (v If <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f� Inspected By Inspector <br /> V p"v1 �,le'n <br /> Physical A dress i 1 1 '- <br /> Inspection Date 5 1 Z 1 <br /> ( /A 15,366 Time In Time Out [ <br /> Business Rep Title V O AM )) O AM <br /> { ® PM I ® 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 /> Q Active ® Passenger I® Generator Q Outdoor <br /> O 0 Closed Q Altered A1/A <br /> GPS Latitude Q Hauler Q Indoor <br /> � Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use j Q Container <br /> Business Type (Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �2 An1e eacy/ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - - ..._ - __.--. ------ -..___ -- _.- _ <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 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 /> 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 1 Q 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 /> ,,action Form Included: r 1 _ ��)t-e-1,6,37- ��6 7 <br /> Comments Included: ® - "� - - - <br /> L/6 <br /> In ep Signature Phone Number sp ctor' nat a Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect I. 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />