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ji Waste Tire _ Ney & Inspection Rer._ _ . Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 0 6 4 5 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> r'--t A- survey_ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> PID- Inspection Type (Fill one) <br /> Site Suffix: j l } ® Routine Q Re-inspection Q Referral Q Observation <br /> Local c If Referral,choose referral type(Fill one) <br /> Identifier: So.�n ��c�cb��_ vVY L�`(� - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address t 1 l ,mb:�lc <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> ' I it PM '� Lr a 0 PM <br /> -- —-- --- — Operational Status Tire Type Business s Role Storage Type <br /> ;L ! <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) i (Fill all that apply) <br /> �j <br /> Q Active ® Passenger ® Generator Q Outdoor , <br /> ® Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> D 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 /> J 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 A j�- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <br /> (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 114 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 /> ---- er n-mc <br /> V <br /> -- <br /> ection Form Included. I ��'_�� <br /> p Q <br /> Comments Included. ®I - <br /> Business Rep's Signature Phone Number Insp tor' Ig ure Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrecti ; ` 62081 <br /> White _____._.. — --- —_---- — - - ■ <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />