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i�. <br /> Waste Tire SLW-ly & Inspection Report Inspection Report Number <br /> Stale of California — <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 I 1 1140890 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN__ <br /> ,Business Profile Inspection Details - <br /> iTPID- Inspection_ ` Inspection Type (Fill one) f <br /> Site Suffix: (G i ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: S - iG „�,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address / - <br /> a2a6 I - <br /> Inspection Date ' z <br /> Time In Time Out <br /> Business Rep Title M ® AM / ® AM <br /> /� v O � PM / C� � QPM <br /> Operational Status. Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / ,J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7 ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 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 ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS J <br /> V A !i HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation O 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. 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 / 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 <br /> T (Required for NOV or EXT) - <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 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 /> Q Q Other: In Compliance - No Violations <br /> jellComments j \l� i7K �'r��1 r --ILr1l� _G ;r�s�,c -l�Yd TGt.�- kLj disc F <br /> Inspection Form Included: Q <br /> Comments Included: ®� ----- ----------- - - ----- <br /> 1 Busmess ep's S gnature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X t MIP !. 12131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />