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Waste Tire S•• :y & Inspection Reportenspection Report Number <br /> State of California <br /> State <br /> WeofCa fornix 04) Survey Form - Page 1 11 - 1141199 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 �, I r, <br /> ���J I J lJ t I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: t. $1L �,l �e,i ) i�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> yC ' tlI Cx (cx rrLAlc ( <br /> Physical Address� �l - I / <br /> I1Z�1- i t;11 <br /> �..__....... f ......_....._......_____..__- ___._. .-..................._.....I r- <br /> Sfreet ! -71 <br /> I Q <br /> Inspection Date - / <br /> �] I <br /> City State ZIP Goc/e Time In Time Out <br /> Business Rep Title � i 0 AM � AM � <br /> JO PM I Q 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 Count(Whole/PTE) I <br /> _ ' T t*Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - ( i Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all t 2t-aply �"� ` <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 /> 0_-- - - ---- - -- --- Q Notice Of Violation Q Extension <br /> 0 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 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/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 t <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> X ._0 62081 <br /> , _. _. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A _+, r <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />