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. Waste Tire Sui Bey & Inspection Report Inspection Report Number ■ <br /> yrrl State of California <br /> CIWMB 04104) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 Il - 1140567 <br /> " t A- Survey___ - BLUE OR BLACK INK PEN <br /> -------- <br /> iness Profile Inspection Details <br /> --I D- � � � � ' � � - �n I �Inspection Type (Fill one) <br /> Site Suffix: v * Routine Q Re-inspection Q Referral Q Observation <br /> Locall If Referral,choose referral type(Fill one) <br /> Identifier — Sty) JoaA LAI <br /> I ) `,( 11+- Q CHP—Q CIWMB- Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> W (- TutLl nj <br /> Physical Address l &n <br /> Inspection Date <br /> Time In Time Out 1 l v <br /> Business Rep Title Q O * AM ( AM <br /> II I ,I I O PM Q O PM <br /> --- -- Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l� Q Active Q Passenger is Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair ®-Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> ------- ----..-...-.__-.-- <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 DateM / 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 E)(T) <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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> (1 1 A 1JV�l�(, �1 fc, ►.IZS(�P.f� f U 1 CL C.1,���-�__ <br /> 0 ac <br /> 1 <br /> action Form Included: QI ��� <br /> 11 (� ►,(� <br /> Comments Included: �' ��t ' O 1�J S�I�- - .610V 16b+3_' 1 <br /> usiness Re Signature Phone Number Inspect s Signature Phone Number <br /> - - - <br /> INSTRUCTIONS ON BACK f Correct:I* Incorrect: It yl } ���t 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />