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Waste Tire Su_ -%.y & Inspection Reports Inspection Report Number <br /> S®3 State of California <br /> Cgrated asteManage Survey Form - Page 1 I 1 - 114119 8 <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i i - j Inspection Type (Fill one) <br /> Site Suffix: (3 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: rt. FA � � V\1 C Q(j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address — <br /> �t l <br /> ki I <br /> 3 ....... <br /> Street <br /> Inspection Date :[t [EIT IQL� <br /> 1 it <br /> St Time In Time Out <br /> City � State ;QIP Code __ _. <br /> Business Rep Title L__ _ .. . Q AM --.. T ®AM <br /> �_ _ O PM / V/ ' O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> Tire CountWhole/PTE <br /> • ) Q Active Q Passenger Q Generator Q Outdoor <br /> Latitudes D Q Closed Q Altered <br /> GPS Q Hauler Q indoor <br /> =.._ (._E ! i I I I <br /> ., .... Q Inactive Q Truck <br /> ( D <br /> LongitudI , i 0 End-Use <br /> Q ContainerQ Planned Q OTR <br /> Business Type ( ppY)�Fill alltfi'w' x <br /> ' <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 QD Other Z-0 l pt)e <br /> _ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - <br /> V A 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 T / m / 17 <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 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 I 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 Q In Compliance - No Violations <br /> Q Q Other: §t <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspecftdr's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E k M P a L E f 2131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />