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■ '=` Waste Tire Su. y & Inspection Report Inspection Report Number ■ <br /> State B California i - 1127661 <br /> COMB Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ -- _ K BLUE OR BLACINK PEN <br /> - - ----------------------- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: O l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /�!� M� If Referral,choose referral type(Fill one) <br /> Identifier: r l <br /> LA YA CJS r V 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> - t <br /> Physical Address 39 <br /> 'tel 51(� A l l ,i i hvt- <br /> Inspection Date <br /> , CC O� Time In Time Out G `/ <br /> Business Rep `Title L O AM 0 AM <br /> �c,�"crc� Z.�m�m�.� I�ICL��;1 •• � r{/�SG� � � � 40 PM ((� �3 7 O PM <br /> - - - - Operational Status 1 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 /> qb Active 0 Passenger I&Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler OPIndoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned ®OTR/ 0 End-Use 0 Container <br /> Business Type (Fill all that apply) raY�C�I <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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder It Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <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 /> / [:E 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 1 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 1 0 Other: § <br /> Comments z � �nC ,n Irk <br /> �,� `?� <br /> I i 2t-AL CJ_ - u <br /> rin <br /> S Cir S — &sY6�L11 <br /> Inspection Form Included: 0 Q- <br /> Comments Included: 01 -_ — _- - - ---- - 1/--��73 <br /> siness Rep's Sig at re Phone Number I e is gn ure Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect N/ X ► - 62081 <br /> - - -- - — <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LE ■ <br />