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Waste Tire Sui _ ay & Inspection Report Inspection Report Number ■ <br /> State of California Il - 1143569 <br /> CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> ------—----- <br /> iness Profile Inspection Details <br /> D- 0� � � - O I Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Stk(�' (7CL �,�I n Cuu� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> U�c_eAs u na �i lis D 1 <br /> Physical Address <br /> Inspection Date � / � � � � O <br /> silo ^ Time In Time Out <br /> Business Rep Title O AM 1 0 O AM <br /> 0 PM 3 1 �J 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 Q Passenger Q Generator Q Outdoor <br /> O ft Closed Q AlteredN NIA �A <br /> GPS Latitude �fl Q Hauler Q Indoor <br /> 0 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 /> 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 /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA 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 EXM <br /> Q Q 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 <br /> ® In Compliance - No Violations <br /> 010 1 Other: § I L <br /> Comments T'&%�SW LJL,4r kl Lot- UfN-1 1S � SMA ilrliI, +-0AU"J4 _S 0 e <br /> 6.fCkfQL <br /> ection Form Included: Oil <br /> Comments Included: Q- <br /> ----- - ----- - - -- -------- ----P-hon-e Number-r--- �Inpe iinBusiness Rep's Signature - -w- - ` Phone✓ZNumber <br /> -- <br /> ------ -------- -( <br /> INSTRUCTIONS ON BACK [Correct:* IncoXrrect: f' J E 3C A, MI PTS E! 1112]3 <br /> I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA I ® ■ <br />