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= Waste Ti►*gufty & Inspection RE Al Inspection Report Number <br /> State B California I l - 1088491 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Business Puo ley BLUE OR BLACK INK PEN <br /> ei inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I I W <br /> ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local / j� If Referral,choose referral type(Fill one) <br /> Identifier: f,� '� ( ( L,1 ` +.(. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Strc,- <br /> Inspection Date <br /> State ZIP Code I Time In Time Out <br /> Business Rep Title Q AM ! Q AM <br /> 4. O PM `1 O � O 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)A <br /> Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m � I Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 4!) 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 O Crumb Rubber <br /> Q Service Station Q Hauler O 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 0 Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance No Violations <br /> O 0 Other: § <br /> Comments <br /> c <br /> Inspection Form Included: <br /> P O , <br /> Business <br /> Comments Included: Q. �._... . _ ,_.-_ - ,a'C�'� -_ ✓'� (t.: l <br /> Rep's Signature Phone Number Inspe or's.$ig ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:r Incorrect: X � � E� X j A M!P, L <br /> White Copy:9IWM8 Yellow Copy:Operator Pink Copy:LEA <br />