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Waste Tire S Vey & Inspection Report Inspection Report Number <br /> .`a ua State B California Il - 1086995 <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey- BLUE OR BLACK INK PEN <br /> BusinessProfile ',p Inspection Details <br /> TPID- } Inspection Type (Fill one) <br /> Site Suffix: - ;T-i Ic- - [c <br /> ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. ( I,,. i 1 '' �( � ) i (_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ac c <br /> Physical Address 1. - <br /> F)T(- i <br /> I `� : \`A i : Ih� rf �4 , - <br /> Street <br /> 1✓ Inspection Date <br /> L i+vState ZIP Code Time In Time Out <br /> Business Rep Title O AM AM <br /> 1 ® PM l QPM <br /> r� I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 101 <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> ® Closed Q Altered <br /> GPS Latitude � • Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 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 <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 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> 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 t 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: § <br /> Comments <br /> Inspection Form Included: Q <br /> i <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number InspeFto)"s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A m FP L E; Z 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />