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LE. <br /> Waste Tire Sui y & Inspection Report nspection Report Number <br /> State of California <br /> CWMB grated Waste <br /> eManag ) Survey Form - Page 1 Il - 1140554 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE O_R BLACK INK PEN <br /> Business Profile Inspection DetailsTPIl <br /> - <br /> Site Suffix: Z 3 - 0 Inspection Type (Fill one) <br /> Site 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> o b 1 ��rY v"N 3 <br /> Phy si I Address f - l 0 <br /> Inspection Date <br /> fidC� � <br /> ,` S 2Yy <br /> Time In Time Out <br /> Business Rep Title ii O AM �l O AM <br /> I s PM 7 ® PM <br /> Operational Status! Tire Type I Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> O 0 Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ®Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber t <br /> 0 Service Station 0 Hauler ® Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 'PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / / <br /> 0 0 14 CCR§18459.1 M M <br /> Tire Program ID Number from CIWMB m <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days ` (Required for NOV,,EXT) <br /> 0 0 III 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 ® Other: § /yCC - <br /> Comments <br /> !Inspection Form Included: 01. �� <br /> Comments Included:IDI <br /> i Business Rep's Signature Phone Number <br /> nspector's Signature Phone Number <br /> �r <br /> INSTRUCTIONS ON BACK CorCct: Incorrect: X " , _ A.E{ �. 2 62081 <br /> White Copy Yellow Copy:Operator Pink Copy:LEA <br />