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Waste Tire Su & Inspection Reportftspection Report Number ■ <br /> ka <br /> State B California I 1 1140875 <br /> CIWMB 18asteManage 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 - n I Inspection Type (Fill one) <br /> Site Suffix 1 r — - l< ® Routine 0 Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 41V1 ,,\, l..Gff.Lt'► 11 — 0 CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Names ' " � I� <br /> rr�� p Ins ected By Inspector <br /> Physical Address - - �) <br /> Inspection Date /� <br /> �tv }Vn C `)5Z S lJ <br /> Time InTime Out <br /> Q AM <br /> Business Rep Title _ <br /> ?� Q AM <br /> O L ' ✓ O ® PM O 3 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J (8 Active ® Passenger ® Generator Outdoor <br /> O Q Closed O Altered <br /> .mss P� Latitude —- -- <br /> o O Hauler our — <br /> O Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> S New Tire Dealer Q Auto Repair Q 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 O 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 AHAULING AND MANIFEST REQUIREMENTS <br /> -- --- - - <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation 0 Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 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 /> I <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: ® (�1 (�� ,I') <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X V r X A Lj4j 1112 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />