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M iN Waste Tire Suf& & Inspection Report Ispection Report Number <br /> State B California I1 - 114089 .1ia Cgrated Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board 3 <br /> PartA-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j G _ D Inspection Type (Fill one) <br /> Site Suffix: ! / _ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �_y.V 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> Physical Address 0 ` fl ` � nt, <br /> ll��o 11a���Jv �• �t <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title S 0 AM O > Q AM <br /> rr `� ®PM 3 ® PM <br /> —- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r 0 Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair *Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 Other: § <br /> Comments <br /> /aA- 11YL S <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> Inspector's Signature <br /> __-Business Rep's Signature Phone Number Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X xj� 2r 1 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />