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Waste Tire Su :y & Inspection Report inspection Report Number <br /> i1 State B California Il 1140968 <br /> Cgrated Waste <br /> eManag) 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- / Q _ O / Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 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 /> I4i r c �CQ- <br /> Physical3 - I D cry <br /> d�� <br /> Inspection Date 0 / I ( 0 <br /> Time In Time Out <br /> Business Rep . 's Title f O AM O AM. <br /> 1"lxu, riC (WW1 ` S� o PM (� O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 57 (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> • 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. i Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 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/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 1 Other: § <br /> Comments L3w�;1'�sl.. (Lt c.�i'��%t-►c3Y'`J OYv y, 7'S, pin>¢, n.tn�'�'(�e- <br /> J' ()1I jo r - -- <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,11 62081 <br /> Li White Copy:CIWMB Yellow Copy:Operator Pink C y:LE ® y <br />