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Waste Tire S- y & Inspection Repore nspection Report Number <br /> 45 3 Srr State B California I 1 1108404 <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 /> Business Profile = Inspection Details <br />} TPID- I I O I C� J - Inspection Type (Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - <br /> 'r.r CM >` -=�., i, � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector j <br /> Physical Address I `� – I ID n.. ��ri�Yl• Y r �/ <br /> >? <br /> Street <br /> r Inspection Date <br /> �rN U V J.1 (U <br /> City State ZIP Code Time In r, Time Out <br /> Business Rep Title 0 AM <br /> 0 PM / O PM <br /> At�o T <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 Count (Whole/PT <br /> Q) Active 0 Passenor >, (p) Generator 0 Outdoor <br /> m 0Latitude t:n� <br /> j � � Q Closed Q AlterecU <br /> GPS 0 Hauler 0 Indoor <br /> —� D 0 Inactive 0 Trucl <br /> Longitude – I I 0 End-Use 0 Container <br /> g 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q 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 r 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 m / m / m <br /> (� 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 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 /> 0 0 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments1d (✓ �i / i _ a no <br /> �( i.1 t '� �r { '� � lrcrl(';�'l'� 111� r (>J� C �� �l✓f_' -�f.( � ,_ <br /> !"D(i7�� ✓!(�t<°��� o �i) (/l i;� l�4_ � 1 C� rr :� y1 U 1 -f'(� � _ <br /> Inspection Form Included: 0 "' <br /> Comments Included: 0 <br /> Business"p's Signature Phone Number Inspector's§ignature Phone Number_ <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1, V :C A F I L 1E1 1/f 62081 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />