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Waste Tire %LjN dy & Inspection Reps. c Inspection Report Number ■ <br /> State CIWMB California I 1 - 11410 0 9 <br /> grated 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- © 1 - Inspection Type (Fill one) <br /> Site Suffix: $ ` v ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> �• Inspected By Inspector <br /> Physical Address <br /> 95S <br /> I Inspection Date 1 O O <br /> (v 2W/_► Time In Time Outt! I v <br /> Business Rep Title 9 0/'� O AM � 0 � * AM <br /> 1 V 0P 0P <br /> �oe, rn��►n v�. (Yl aria ye,� - - - - - ----- -- ------ <br /> - ` - --- -- --- - --J---- ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l� Active e Passenger ®Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler � 0 Indoor <br /> 0 0 Inactive 01111Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 ® Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 11-1 V I A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 ;PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 j 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 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 0 114 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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> C \ ; ;mss ¢.c4�r� r -17.� is � t, <br /> Inspection Form Included:• ` <br /> P <br /> Comments Included: GI <br /> - --- -— - - <br /> a-m—­ <br /> r081 s Rep's Signature Phone Number Inspe Signa re Phone Number <br /> �� ( <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect. X I"Get N X AI 1 j 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: ■ <br />