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aWaste Tire S ey & Inspection Repolo Inspection Report Number <br /> State of California <br /> CIWIVIB Waste <br /> eManage) Survey Form - Page 1 I 1 - 11413 31 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` I 1 ' j Inspection Type (Fill one) <br /> Site Suffix: ` 11 [ <br /> Routine O Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: �a1� � �� �1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 1 1 V►'C.1 \ Q I 0 'n <br /> e Inspection Date <br /> 0 0 <br /> CA 2sigo d <br /> Time In Time Out <br /> Business Rep B Title 5 S PM PM <br /> -- <br /> y Operational Status Tire Type Business Roll�tor <br /> Tire Count (Whole/PTE) age Type <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � <br /> Active S Passenger 41 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler ® Indoor <br /> O O Inactive • Truck <br /> Longitude — O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber <br /> 0 Service Station Q Hauler O Agriculture Q Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS j <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ._. ........._. Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § j <br /> Comments 1 <br /> Tom- r CJL Pe(i S 4 (0c)C�.rn • <br /> ilnspection Form Included: Q 4Phone <br /> Comments Included: QBushes s Si nature umber Insp or's Signature . Phone Number <br /> INSTRUCTIONS ON BAC Corr ct: Incorrect: X 1 EJXJ AIMI P I L I El 112 3 62081 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />