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■ A,. Waste Tire S Y & Inspection Repor%Inspection Report Number <br /> State CIWMB California I 1 - 10 8 8 0 3 5 <br /> . � grated Waste <br /> eManage Survey Form - Page 1 <br /> California Integrated Waste Management Board - <br /> Part A- Survey.. _ _ <br /> BLUE OR BLACK <br /> Business proftlQ Inspection Details <br /> - , L <br /> Site � Inspection Type (Fill one) <br /> Site Suffix f fLL L Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier: J D Q U 1(1 CO U U <br /> J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> • ----_.__.__I <br /> Street T- <br /> -- <br /> Inspection Date ZC�__--._ �— TimIn Time Out <br /> _._.____...._.__ <br /> State SIF'(,-ode i-e .._ �-6F(­ <br /> _..__ <br /> Business Rep Title 0L.J.. 4 AM 0 AM <br /> OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Fill one only) Fill all that a (Fill all that apply) (Fill all that apply) <br /> fo Active Q Passeng ® Generator Q Outdoor <br /> LLI <br /> Hauler Indoor <br /> Latitude QClosed Q Altered <br /> GPS 'i I _ O O <br /> Q Inactive Q Truck <br /> LongitudeQ Planned Q OTR O End-Use Q Container <br /> Rosiness aype (Fill all thai 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 OQ Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other. § <br /> Commentso:.Atrt a. 1"t1.�D iz2 Fw n pst.r or&-ea 1 ftl:s <br /> ---� �' date 4 fi$e -6110W 1_nq was notea- - <br /> �p�r�• 12� u��yt-e sed -'ctires_. �tored on-�►fe. Fc�c.illt�� �Oritl'uc.'�s �,uith ��,-� -1"tr� . <br /> J <br /> or �u��r/ase �re rErr�oY;a\ . GRL_ m- t-��--Nave �,ot n YA- __e � c)__ <br /> G}CZ Nfir, ./ I <br /> Inspection Form included Qr ✓ <br /> CommentsIncluded: O Business Rep's Signature Phone Number Itspedor's Signature ;,,^ ..•4, ,f „~Phone Number III <br /> - - - - <br /> _ .. .._ - ; 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ;; Mo "rr�" pY" 13 E <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />