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ori_ 'Apection Report Number, <br /> zC - Waste Tire S ' & Inspection Repo <br /> 8E.8 State of California <br /> ' ■ <br /> NU6ii CIWMB 181 New 04104) Survey Form - Page 1 ; I 1 - 1108 4 <br /> Kalifornia Integrated Wasted Management Board <br /> PartA- Surve BLUE OR BLACK INK PEN . <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: a 1-7 ' ® g Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: Xt t L-4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> (, e- <br /> (Physical Addrbss <br /> 1, <br /> ctJ� l <br /> Street <br /> Inspection Date <br /> City aar State ZIP Code I Time In Time Out <br /> Business Rep Title Q AM �'`7� Q AM <br /> 1 PM 3 ✓ 4@ PM 9 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count <br /> (Whole/PTE) I -- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger 40 Generator f Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude0 Planned Q OTR 0 End-Use 0 Container <br /> — U <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel ` <br /> -Used Tire Dealer 0 Auto Body 0,Car Dealer 0 Collection ().Crumb Rubber <br /> J <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder a Other � �� �t t � S <br /> K• �+5 <br /> Part B.- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS — <br /> FV_A HAULING AND MANIFEST REQUIREMENTS <br /> 0 I 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> PRC 42953 Contacts with Registered Waste Tire Haulers. <br /> § _ g Compliance Deadline <br /> 0 ! 0 PRC§42956-Registration/Decal in Vehicle <br /> m <br /> 0 ; 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB I <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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manife\t 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 — <br /> Le <br /> Inspection Form Included: 0, <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number <br /> inspector s S'gflature Phone Number <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect: X)( 1 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy: ■ <br /> i <br />