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Waste Tire S y & Inspection Repolnspection Report Number <br /> i; State of California ■ <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 I1 - 1143816 <br /> California Integrated Waste Management Board <br /> Part A- Survey - -_-_ __- -- --_ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- ' o c _ ® I Inspection Type (Fill one) <br /> Site Suffix: J (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �O� If Referral,choose referral type(Fill one) <br /> Identifier ,tw f) 0141 f <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 v n F GO1fo <br /> � Inspection Date ® 1 (v)1 <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> -So,t- L kc 6 0- A��L7 T�CJI-S 1. - I : 3 V a PM a S 40 PM <br /> --- - 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 /> f 0 Active ® Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude — 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 • 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date FF / m / M <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O - _- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§ 1.8462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> of C�ncer� <br /> -N-Acc. L FktAk'� _-r �,V\ 6S -FIc f rct,-i cs w hA- - e.r. - <br /> Inspection Form Included: Q�, / ' <br /> Comments Included: QI - rSignature �� - ;S �g�� 'XJI�V`V cl0 I I s RpPhone Number Inspect Signature hone Number <br /> INSTRUCTIONS ON CK Correct:* Incorrect �( �/! !r X A M 1 i 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop Ulf <br /> :LE ® ■ <br />