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nimspection Report Number <br /> Waste Tire Su, y & Inspection Report <br /> State CIWMB California <br /> H Il - 1140657 <br /> California Integrated'Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> I <br /> Site Suffix: 1 '� - © ( Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - ,`�/ !Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address !� <br /> z3�-o� l✓Zal . <br /> Inspection Date <br /> CAS IF5o20 9 +� r <br /> Time In Time Out <br /> Business Rep Title � 2 s- ® PM �� �� AM <br /> ® PM <br /> -- i Operational Status Tire Type Business Role Storage Type <br /> I(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active I ® Passenger ® Generator i, ® Outdoor <br /> - - - O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 1 Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS' <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> -- Q Notice Of Violation Q Extension <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 (Required for NOV or EXT) <br /> i <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 /> 1 <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations' <br /> Q Q Other: § j <br /> Comments <br /> wers <br /> Inspection Form Included: Q <br /> O�_Co ® Business e s -t i — - - �� �Signare <br /> mments Included: - - p' g e P e Number InspePhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [C Ineorret« 1 <br /> t <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />