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Waste Tire Suty & Inspection Repor*inspection Report Number <br /> State of California <br /> CWMB 1(teManage) .survey Form - Page 1 1 - 11412. 21 <br /> California Integrated Waste Management Board �. - --- -. --- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 15 -5 (� V Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: JLG U I r ( G(/Y1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> ._j i /��rC i i ClL lit <br /> i._.��! :.-. .....- _._....... <br /> Sheet E l n t <br /> Inspection Date a' <br /> � L <br /> ZIP_ ode Time In Time Out <br /> Business Rep Title i �� AM ' ; . ._ 0 AM <br /> �- OPM _ �15 OPM <br /> L4j� 11 - I A, LOperational Status Tire Type Business Role Storage Type <br /> Tire Count il"i4Yle1P1,E'y (Fill one only) {Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ; Q Active 0 Passenger Q Generator Q Outdoor <br /> I I Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q indoor <br /> .....r.--_; ...-.__.. r..... .l� Q Inactive Q Truck <br /> Longitude <br /> — ( Q Planned Q OTR Q End Use 0 Container <br /> 9 <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 Q Other � i ��1 .•7�r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 'HAULING AND MANIFEST REQUIREMENTS _ 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. 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 / E[1 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 0 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 I CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § i- <br /> Comments `1 <br /> �iC31isi _ ���ial\1`- <br /> 1 ic; l �-- -tom - c., -- <br /> -- <br /> tspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: X -1/1, °.ii X AuAk � ��M��^ <br /> iWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />