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Weste Tire y & Inspeetion Repo Inspection Report Number <br /> '^ 'i• State of California <br /> °r CIWMB1811(New nage Survey Form - Page 1 I 1 - 1086953 <br /> - California Integrated Waste Management Board - -. - <br /> Paq A- Survey BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: � �� ® Routine Q Re-inspection Q Referral Q Observation ! <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: f{ ,� �! <br /> �_.1_._.�. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - L .- - d ( <br /> Street ) <br /> Inspection Date <br /> f 9 <br /> ':rtl State ZIP Code Time In _Time Out _ <br /> Business Rep Title; f Ed <br /> AM AM <br /> 0 PM 0 PM <br /> - IT <br /> - - Operational Status "Tir"eType'" Business Role _9'torege >y , <br /> Tire l;Qllnt'(WhOI�iPTE) p ( �t1!(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all iltat apply)1 <br /> i ( -�. <br /> - u Active Q`Passenger Q Generator Q Outdoor <br /> - 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler (j) Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FTI / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 1 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> - - -. --- ----- -- ---ori-- — - <br /> I' <br /> Inspection Form Included: Q ) <br /> Comments Included: Q ' ! <br /> Business Rep's Signature Phone Number inspector's Signature <br /> 2� y done Number <br /> - - 1= 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: f X�A M P; E 1 2 <br /> SWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />