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Waste Tire SAW & Inspection Reportftpection Report Number <br /> State CIWMB California I - 114 0 6 0 8 <br /> grated 1st(New Manage) 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 Type (Fill one) <br /> Site Suffix: 3 .Z 0 0 0 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCAM 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> P � <br /> Physical Address <br /> qo y o e s Lam - <br /> CA 1.5� - <br /> Inspection Date <br /> � <br /> � � i <br /> Time In Time Out <br /> Business Rep Title <br /> / /� Q AM Q AM <br /> O / 7 ® PM ! S ® 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered / ,/A <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O Q Inactive �Truck <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 0 Agriculture 0 Shredder • 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 <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 _ <br /> 0 0 Other: § In Compliance - No Violations <br /> - - - - <br /> Comments <br /> le4'e.'Ama crxe A�.� all. 4ta'5 <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> sine Rep'4Sige Phone Number ectoes Signature Phone Number <br /> INSTRUCTIONS O BA Correct:0 Incorrect: X ter 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop'L ® ■ <br />