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Waste Tire Sue .ay & Inspection Report , Inspection Report Number ■ <br /> CIWMB811ifor <br /> (New04104) Survey Form - Page 1 I 1 - 1140681 <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ) Inspection Type (Fill one) <br /> Site Suffix: l S 9 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ll/l� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 7SL -75 ID ccxn4- A <br /> Physical Address30 <br /> 1 fejt j -�1 �t�j <br /> Inspection Date � / � •--7 � ' <br /> T1eti� Time In Time Out <br /> Business Rep Title7 O AM 77 O AM <br /> vL PM J 410 PM <br /> ��::(.�(1.1�. .L.ICX�✓1^� fie,+.- -- --- - - — - - <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 (Whole/PTE) y <br /> ®Active ®Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler a 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 /> ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i ENFORCEMENT STATUS <br /> VV A j HAULING AND MANIFEST REQUIREMENTS <br /> 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. <br /> Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 114 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 114 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E>M <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> L <br /> Inspection Form Included: 0 �Rjep's®, <br /> � 7 <br /> Comments Included: 4!�, , Signature Phone Number 46edjorg' �Ignatujlft <br /> — _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X �,: X JAM P 1 1112131 62081 <br /> - - _ ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />