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a <br /> Waste Tire Su. .6y & Inspection Report 'inspection Report: Number ■ <br /> State of California 11 - 1143462 <br /> CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLU_ E OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- O � Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /{' If Referral,choose referral type(Fill one) <br /> Identifier: S AnJ o ff A Cl( � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> D-3S <br /> Inspection Date v ` ` 0 <br /> Time In Time Out <br /> Business Rep Title � vl O AM OAM <br /> J �/ PM I 0- © PM <br /> (3,0kn �OT��S �aA)o-1(Agr <br /> Operational Status Tire Type Business Role <br /> -- -` --- - ---- - - -- Storage e <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all thatTypapply) <br /> Tire Count(Whole/PTE) 7 1 y 5 <br /> ® Active ® Passenger Is Generator ® Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) j <br /> New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> ®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 I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O ® 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 11 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> O 0 Other: § -- -- ----- <br /> Commentst 1 .� <br /> -....-- 1 N�. �J0.bT�,—�.fc�1QS(�r� t pn_ � um-4 o 1-S_ c (d.-nc ---..- -- <br /> Inspection Form Included: Q - <br /> Comments Included: i <br /> Business Rep's Signature Phone Number Insp�IsSignajre Phone Number <br /> INSTRUCTIONS ON BACK ! Correct: Incorrect: Ak A 1 1 2 62081 <br /> - _ - ._X - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :L 0 <br />