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■ Waste Tire Sull _ 41y & Inspection Report Inspection Report Number ■ <br /> State of California 11 - 1143839 <br /> CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey___ BLUE OR BLACK INK PEN <br /> - ----------------- -- <br /> Business Profile Inspection Details <br /> TPID- �] (`, Inspection Type (Fill one) <br /> Site Suffix: t Cz 6 ") 1 _ � j � Routine Q Re-inspection Q Referral Q Observation <br /> Local ��y L /� v1 If Referral,choose referral type(Fill one) <br /> Identifier: 1.1 � l/� 6CA A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business orr�Facility N me Inspected By Inspector <br /> Physical Address 6 1 (� ynjj; <br /> Inspection Date :;2 1 o <br /> Time In Time Out <br /> Business Rep Title l ® PM l ® PM <br /> Operational Status1 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) � Q <br /> f f ®Active Q Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive �Truck i <br /> Longitude — 0 Planned OTR O End-Use Q Container <br /> i <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS _ <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O 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 EXE <br /> 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/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 In Compliance - No Violations <br /> O O Other: § <br /> Comments RO1 I✓ TMtYl 19el t'//__ ^_____ <br /> �l" eCe 6A 7M "Ac <br /> !Inspection Form Included: <br /> p Comments Included: O ' , <br /> �� f -- - <br /> u t ss R p's gnature Phone Number c gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i , p Ir 62081 <br /> ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: EA <br />