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Waste Tire SUW & Inspection Report nspection Report Number <br /> State B California ry I 1 1127676 <br /> Cgrated Waste <br /> eManage) SurveyForm - Paye 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey ___-- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Q � Inspection Type (Fill one) <br /> Site Suffix: 3 69 <br /> M ® Routine Q Re-inspection Q Referral Q Observation <br /> �Local Lr,,n �vv' I 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 /> CYN C <br /> Physical Address <br /> i(�4Gv <br /> r� <br /> nn CGl VYl P° ��gg�o Inspection Date � � I C� � J <br /> C �tl l <br /> Time In Time Out <br /> Business Rep Title 7 O AM r O AM <br /> . � � .J � � <br /> Peke &Lywo),\ Flon'f- I&K -- �PM 0 ® PM--- - -- -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) + rJ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger ® Generator O Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler indoor <br /> O Inactive ® Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 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 O Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 0 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 /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcement <br /> Q 0 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 <br /> In Compliance - No Violations <br /> 0 Q 1 Other: § <br /> Comments �r \ r C <br /> IA/o /,:=L:A�w <br /> 'Inspection Form Included: <br /> Comments Included: Q - - `61f—1y-1" <br /> slss Rep's Signature Phone Numbers I ct ignature Phone Number <br /> INSTRUCTIONS ON BACK Forrect Incorrect J� �/^ P e :�I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />