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Waste Tire 4"1 & Inspection Reppection Report Number <br /> ■ I® State of California T 1 ■ <br /> Califo�miaIntegrated WaseeManagementBoard Survey Form - Page 1 i i 114 3511 <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C7 Inspection Type (Fill one) <br /> Site Suffix: S 1 © , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Say Jpcl`�Ultf� CljU,fl�l� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �4o Al <br /> ells 3 q - l R, <br /> Physical Address a <br /> 12.L1 <br /> r-- . <br /> SA aC\_JCA 15a(35 Inspection Date ' I I O <br /> Time In Time Out <br /> Business Rep Title11- 40 AM B AM <br /> Mor1\rC(Y1Cif11 L J v O PM 0 5 0 PM <br /> ViC[or ��,`i��-� - <br /> — — -- - — -- Operational Status Tire Type T Business Role Storage Type <br /> 1 ` <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ,`v^ <br /> ®Active ® Passenger 1@1 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O <br /> Q Inactive Q 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 ®Auto Body 41 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A I HAULING AND MANIFEST REQUIREMENTS <br /> 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 O PRC§42956-Registration/Decal in Vehicle <br /> Q l O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> Q i • 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§.18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § l- 1 <br /> Comments Q-D �L �_ �ifl�`21l� S Qn r11�� 7�Cl 1 <br /> Inspection Form Included: QI <br /> �t` <br /> Comments Included: 0� �' � T�/ <br /> Business Rep's S gn ure Phone Number Inspe is Signature Phone Number <br /> y1 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect "v �/ 1 )C r� l f� L 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator J Pink Copy:LEA ® ■ <br />