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Waste Tire _.rvey & Inspection RepL _ Inspection Report Number ■ <br /> 91i1 State of California <br /> CIWMB 781e ) Survey Form - Page 1 I 1 - 1143640 <br /> California Integrated Wastt Manage <br /> Waste Management Board <br /> Part A-_Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l l/ O Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: I;Z,5w, � �s i l f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> r' <br /> Ph sical Address A, 7/ /1 - rn�.L)L,_t lJ <br /> ff Inspection Date , <br /> Time In `J Time Out <br /> Business Rep Title O AM _ <br /> f�'`'�� <br /> O AM <br /> 0 ® PM PM <br /> �r1h �Jc2+r� I�bL.YVtc1a�� ® tr <br /> - - - -- ----- — �- — - - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 9 f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> -- - O- Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation <br /> Q 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 / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> QQ 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FJC� <br /> Q <br /> 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 In Compliance - No Violations <br /> Q O Other: § --- ----- <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included <br /> Business Rep's Sign a Phone Number In org ature Phone Number <br /> - - - --- - <br /> INSTRUCTIONS ON BACK 1 Correct:0 Incorrect ( 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />