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H _ <br /> y <br /> Waste Tire SL ,y & Inspection Repo Inspection ReporL Number <br /> -.cv:: State B California I 1 - 1108407 <br /> rnia Cgrated 1steManag) 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- Inspection Inspection Type (Fill one) <br /> Site Suffix: `-7 tL tJ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � 'If Referral,choose referral type(Fill one) <br /> Identifier: 0 C( C./ t,(r\ 911 r-k- � ti' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l ( ) I Inspected By Inspector <br /> Physical Address �._ 1 r - J I J i'1 t f� <br /> Inspection Date ` <br /> l �. <br /> /G <br /> State ZIP Code Time In Time Out <br /> Business}}Rep Title I Q AM Q AM <br /> j t� �',r T(Operational <br /> QPM O 3L� �' QPM <br /> Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE (Fill one only) (Fill all that aPPIY) (Fill all that aPPIY) (Fill all that apply) <br /> Active 0 Passenger Q Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all thaE appfy) - <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 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 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 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 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 /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - INS �I PT1c., i _ 62081 <br /> INSTRUCTIONS ON BACK Correct: X I X t A, ,N,Incorrect: � � � Li 1 ,� <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />