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E jjWaste Tire SL. - ay & Inspection Repoi . Inspection Report Number ■ <br /> State CIWMB California I 1 - 112 7 6 6 9 <br /> grated Waste <br /> eManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � � � I Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Localr,_ ^ If Referral,choose referral type(Fill one) <br /> n <br /> Identifier: S u` ) J 0(;� �1 W1�'\ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Fcility Name Inspected By Inspector <br /> to <br /> Physical Address { l O I &S Lo tt o <br /> a^SUS ®� • <br /> Inspection Date � � � % / l <br /> Time In Time Out <br /> Business Rep.. 11 ,,A Title M 0 O AM O AM <br /> I V` Q&r ��1 wn V-' ' Y Wn 1 t t --O <br /> PM Q O PM <br /> --�"'- ' ,V--- - — 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 10 Generator 16 Outdoor <br /> O 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 /> 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 4D 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 /> V 1 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q li Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 1 Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 1 Q li 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 010 Other: § <br /> Comments �fk. ►()J10CA11 dj\ ptr ().)M-V'� <br /> ---- <br /> Inspection Form Included: Q, <br /> Comments Included: <br /> 01 Business Reps Signature Phone Number Inspec r s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect I 3 62081 <br /> - �I SIA ! �II <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop , �� ■ <br />