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963 <br /> Waste Tire Sur. sy & Inspection Report .•ispection Report Number <br /> tl State CIWMB California I 1 - 114 3 5 5 7 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- h � - f_ i Inspection Type (Fill one) <br /> I <br /> Site Suffix: S 1J� v U l * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 5 Gtl,n s om U,, n COu Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t <br /> Inspected By Inspector <br /> oU �I _ <br /> �i f Q� I 1 (� <br /> Physical Address ` l ` <br /> LA�('� Inspection Date 5 � � y � � Q <br /> X C� ����� Time In Time Out <br /> Business Rep �,( e Title e 5 0 AM O AM <br /> �J 4j )\\2(1l j Ulla Sal l 0 PM ® PM <br /> y- slti► _ <br /> - --- - - - -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 1 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 40 Generator 0 Outdoor <br /> Latitude <br /> 0 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 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 /> I 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. 1 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 <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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 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 <br /> 10 in Compliance - No Violations <br /> Q Q Other: § <br /> Comments \ I '_ f <br /> Inspection Form Included: Q a ® <br /> 'lqq 1 Q <br /> Comments Included: - - - -- <br /> sin s Signature Phone Number Inspect 's Signature one Number <br /> INSTRUCTIONS ON B CK Correct: Incorrect: I VI X 1;�4 I 1 ' 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co ® ■ <br />