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Uri <br />pr is <br /> Waste Tire Su, _y & Inspection Report ispection Report Number <br /> State of California <br /> CIWMB1811st(New Manag) Survey Form - Page 1 Il - 1140789 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection/ Inspection Type (Fill one) <br /> Site Suffix: O_ (r� — Routine: Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `7�,�.� -meq CHP CIWMB Complaint <br /> �" � Q 0 p Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Address <br /> Dr <br /> � <br /> CA <br /> Inspection Date 6 02 ! 1 G�vclt.-fTJr�- ���d U(� e <br /> Time In Time Out <br /> Businless'Rep Title Q AM � a S Q AM <br /> © <br /> Lig ® PM ® 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 /> ®Active ® Passenger 4 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - - - -- —---- - - -- <br /> p New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government p Retreader Q Dismantler 07-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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 1 V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q O 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <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 f CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> 01. i vl <br /> -- <br /> inspection Form Included: Q <br /> Comments Included: ® - .2 �0�-�6z3 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: X IE X A`: PLZ I <br /> 112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py:L <br />