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t= Waste Tire Su 01 & Inspection Report Ispection Report Number ■ <br /> State B California 11 - 1140879 <br /> q rated W st(New04104) 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: 3 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Suy� t r Vu 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> If n i f cj- P44-UX <br /> Physical Address 3 Cf - Q <br /> CA- <br /> 1-S32 ��, � rol�cc W <br /> CA Inspection Date <br /> `I��aS 7 <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> I �� G ® PM S 0 PM <br /> Operational Status I 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 /> 0 Active ® Passenger 0 Generator ® Outdoor <br /> P$ Latitude <br /> O 0 Closed 0 Altered <br /> G 0 Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - 0 Planned 0 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 <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 <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 10 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 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 0 Referred f 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 Generatorsilf In Compliance - No Violations <br /> 0 Other: § <br /> Comments <br /> --- — <br /> Inspection Form Included: 01 <br /> Comments Included: 0 ✓\ <br /> Bus nes Re s igna re Phone Number spector's Signature Phone Number <br /> - - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X I~`X :, P 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y: <br />