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Waste Tire Sum..y & Inspection Report ,ispection Report Number ■ <br /> State of California I 1 - 1143586 <br /> Cgrated Waste <br /> eManag4) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> D- <br /> ` _ O Inspection Type (Fill one) <br /> Site Suffix: 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localr t If Referral,choose referral type(Fill one) <br /> Identifier: S Can J O(J n �V1J1�1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> in <br /> Busess or Facility Name 1w <br /> Inspected By Inspector <br /> S cu� y I W <br /> Physical Address 3 1 l �e(1 CS�Ob <br /> �vuy aril Qs,,,.d� �slwn(� �u� d;ny too), <br /> l J�3 Inspection Date CA J Time In 1 Time Out <br /> Business Rep Title G� O AM Q AM <br /> ' J PM v PM <br /> --- - -- - - - - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (aI (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger 0 Generator Q Outdoor <br /> - -- O le Closed Q Altered Nl� <br /> Latitude <br /> GPS Q Hauler i Q Indoor <br /> O Q Inactive Q TruckN IA 1 <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> (l New Tire Dealer Q Auto Repair • 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 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 � Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 (8 In Compliance - No Violations <br /> Q Q (Other: § <br /> Comments L <br /> -- --1 n► �a�►n_ S�io_r�C�wr1�- (rel��s ���t�rl�#�c,-�� �n"1�1�S_�(1��T. <br /> sux-k a _ s_no i n <br /> action Form Included: Q <br /> Comments Included: Q �J�-0►W C�C11 -llpp'3��p <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />