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w <br /> ■ i =t11 Waste Tire sur. _y & Inspection Rep,, t nspection Report Number ■ <br /> State CIWMB California I - 114 0 8 31 <br /> grated 1stdeManag) Survey Form - Page 1 <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: / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: �� t✓' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A ' _ <br /> A Qss i / � <br /> Physical Address 9 `) V <br /> q <br /> 1 ' Inspection Date 1 ) � `� fr'1 <br /> f 1 avj�Cc.r� C�4 336 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 3 ' <br /> 1 -S70PM 41 0 P <br /> L-aVrL\----LAS-�---- -- — - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ,off (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 ® Active Q Passenger ®Generator 4@1 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive I®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 Q 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 /> 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 / 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 E)M <br /> Q 014 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 I Q Referred I CIWMB Enforcement <br /> Q 1 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 ® In Compliance - No Violations <br /> 010 Other: § <br /> Comments <br /> Inspection Form Included: Qi - a��l 25 0�/2<✓{r_5 <br /> d� J I Y! <br /> Comments Included: -- <br /> Business Rep's Signature Phone Number InsWp isSi ure Phone Number I <br /> _t _ - -- - - <br /> INSTRUCTIONS ON BACK Correct. Incorrect 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />