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® _ _ Waste Tire Su ay & Inspection Report Inspection Report Number ■ <br /> ➢7i3 State of California — <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 I1 1140716 ' <br /> California Integrated Waste Management Board <br /> Part A-Survey -_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' 5 2 U 1 • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sc"LV 'jCCtC i,� C�tiV.,I� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J -- <br /> c Inspected By Inspector <br /> Physical Address <br /> CA Is 2 ; ,s- <br /> Inspection Date v �? C-) I <br /> Time In Time Out <br /> Business Rep Title O AM Gh Q AM® PM l ® PM <br /> - <br /> --- - - -- ---- -- -- - --- - - - - --- Operational Status) Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) F 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> IS Active -Q Passenger— 40 Generator -Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 r,, <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 / FrI <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 /> 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 /> Q Q Other: § <br /> Comments / <br /> K1.4 ;PIC jx.i)47LF11 c� --47�6,`� -G� 1. c—,- �-—I 'll V�,c.�i PT--- <br /> C»- <br /> Inspection Form Included: Q X <br /> Comments Included: Q <br /> ���� i -o 3 <br /> Business Rep's Signature Phone Number Spector' Sign ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X V { A l! l_ I i 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy� <br />