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f ttijWaste Tire SL :y & Inspection Report Inspection Report Number <br /> is State of California 11 1141269 <br /> CIWMB1811(teManage) 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/ ®nspection Type (Fill one) <br /> Site Suffix: �J✓� l/J\ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r� \ If Referral,choose referral type(Fill one) <br /> Identifier: 1. •t✓ 1 1 � L'7�V 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (-1 Inspected By Inspector <br /> Physical Address J / I <br /> I;nl� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title n fr 0 AM 0 AM <br /> l I' 0 PM 0 PM <br /> tL� e ` (� /� - Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR I 0 End-Use ® Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 1@ Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS :rr <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> 0 0 Other: § <br /> Comments l <br /> Inspection Form Included: 0 <br /> 73 Comments included: 0 �— ` '� --- <br /> Business Rep's Signature Phone Number Insp ctor's Sign ure Phone Number <br /> - 62081 <br /> a:^1S7',.3U-IONS ON BACK Correct. Incorrect. X", E.XC AM. F L E -11131 <br /> Ph;tc. y:CIW7Ag Y.:?llcw Copy.Operator t ir,k Copy:i..,-_A <br />