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Waste Tire SL&y & Inspection Reporislnspection Report Number <br /> CaliforniaState B California <br /> ass <br /> Cgrated 1(teManag) Survey Form - Page 1 I 1 1127630 <br /> Integrated Waste Management Board - - -- - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Mirl.ess Profile Inspection Details <br />} TPID- ! I f Inspection Type (Fill one) <br /> Site Suffix: _ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f j 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 <br /> Inspected By Inspector <br /> 0_1 <br /> ►✓ � r .. <br /> Physical Address r I — 1 ! 1/ <br /> t_ 1...... v._.._.........._.. .. ......_.._... ._.._.__.. ___..__.._.:............. _._._.._._.._.___._......_._._...._._._! ; <br /> S reel 671 <br /> Z_ (,./r Inspection Date <br /> Time In Time Out <br /> Business Rep Title ,3te . tR Cotte .r_ A <br /> ... _ M 3 _ AM <br /> r i <br /> O PM f ! l O PM <br /> __ __._ _....._ ...... .._ _..... .. "....-..t <br /> Operational Status Tire Type Business Role Sforoge Ty tae <br /> (Fill one only) (Fill all that apply): (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/ITE) /'� <br /> 7 Active Passenger(� g�, 0 Generator �_� Out <br /> O 0 Closed 0 Altered <br /> _._s�"__ Hauler (� Inioor <br /> GPS Latitude I <br /> I 0 Inactive 0 duck <br /> 30 <br /> Longitude j Planned }rR� 0 End-Use 0) Cohtalner <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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 DateM / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB EE <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 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 0 in Compliance - No Violations <br /> 0 0 Other. § <br /> Comments f {� j f a ` <br /> �.�e� n�v 1 the fog u;Q ;f `S,oD <br /> . . '. e� <br /> Inspection Form Included: 0 <br /> Comments Included: 0 ' <br /> Business Rep's Signature, Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � yea, 62081 <br /> �. �: �=! �_ 6 1 � . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />