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Waste Tire Sui Bey & Inspection Report Inspection Report Number ■ <br /> WMB 81California <br /> 04104) I 1 - 1143509 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey -__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Ins Inspection Type (Fill one) <br /> Site Suffix: "� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sat) J 00',u'r) �1,i ni Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> W �rs�; Sl4vS 04 <br /> Physical A ress <br /> L � <br /> �� `1'Is�3'o Inspection Date 1 I <br /> fo� I <br /> Time In Time Out <br /> Business Rep Title �f 0 AM U 0 1 0 AM <br /> J ' al 5 0 PM 1 V V (6 PM <br /> Operational Status 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(WholelPTE) '� 5 <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 IENFORCEMENTSTATUS <br /> V A I 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 li 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 / m / 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 EXT) <br /> Q O - - -- - <br /> 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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q it In Compliance - No Violations <br /> Q Q Other. § — --- <br /> Comments 1�1 r� r)S 0f CY LA — <br /> J <br /> Inspection Form Included: Q <br /> Comments Included: Ila /rl <br /> ep- nature Phone Number Inspec is Signature ( hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X 1 ; 1 2131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />