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Waste Tire Suk .ey & Inspection Report Inspection Report Number ■ <br /> State California I 1 - 1140929 <br /> CIWMBB 181( eagSurvey Form - Page 1 <br /> California Integrated WasttMan <br /> Waste Management Board <br /> Part A- Survey _- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 9 1 _ Inspection Type (Fill one) <br /> Site Suffix: l ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sam Joy �" (0"kq Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> vi <br /> Physical Address <br /> lu <br /> Inspection Date ( a , d 1 � ( 6 <br /> tkA6f t,, Time In Time Out <br /> Business Rep Title 1 O AM 1 O AM <br /> oc l 0 PM l 111111111 PM <br /> ------ — ---- — --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 46 Active Q Passenger ® Generator I* Outdoor <br /> GPS Latitude Q Closed Q Altered Q Hauler ® Indoor <br /> 0 Q Inactive ® 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 41 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 <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 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 <br /> m / m <br /> 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 /> 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 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ff 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § ® In Compliance - No Violations Comments f c 1 nS l O _ �1n' J <br /> 'RA' Lu1(� <br /> OA <br /> Inspection FormIncluded: Qi — <br /> �Bu,�nL Comments Included p' Ignature Phone Number -- Insp ors Signature Phone Number <br /> - ---- ------ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect t I XIA p 1 213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop <br />