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Waste Tire Garvey & Inspection Rep`. t Inspection Report Number ■ <br /> CIWMB California <br /> 1(New04104) Survey -Form Page 1 Il - 1140647 <br /> California Integrated Waste Management Board �J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Iness Profile f Inspection Details <br /> ..,ID- Inspection Type (Fill one) <br /> Site Suffix: �j l * Routine Q Re-inspection Q Referral Q Observation <br /> Local ��r` If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date 1 <br /> CA g5376 <br /> Time In Time Out <br /> Business Rep Title, - O AM //��y, O AM <br /> Ietuy% 3 0 a PM a/- 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 /> Q Active ®Passenger 6 Generator 40 Outdoor <br /> o ® Closed Q Altered <br /> GPS Latitude Q Hauler i Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ik-1 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 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 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 I* In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> .ection Form Included: Q <br /> "-74, �zr-yyv�2Y� rte-_4x46 P6 7 <br /> Comments Included: 01 - --- ---- - - <br /> __ iness Rep's Signature — —Phone Number In o S' nature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: I E X �' r 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />