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Repo nspection Report Number <br /> Waste <br /> Tire S & Ins ectior`n e <br /> ■ ' C8 State of California Y <br /> °°� CIWMB 181(New 04104) Survey Form` Page. 1 11. 10 8 8 416 -� <br /> .California Integrated Waste Management Board <br /> Part A.- Survey -__- BLUE 6% R BLACK INK PEN <br /> Business Profile ;Inspection Details <br />+ TPID- – L r tt r— -_ Inspection Type (Fill one) <br /> Site Suffix: i Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one <br /> Identifier. ) <�. t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ICC°� :, <br /> Physical Address - <br /> • <br /> 1 -fo tI - <br /> Street r Inspection Date <br /> /" ZC:_ � I <br /> City State ZIP Code Time In Time Out <br /> I Business Rep Title _, rr O AM _ O AM <br /> EV� (9 PM PM <br /> I ���,{ 1 ,- kms• � 1�.,L .'' / II:,. ,� �• I �- _..• - <br /> Operational Status Tire Type I Business Role Storage Type <br /> Tire Count(Whole/PTE) / i� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> —1 (0 Active Q Passenger I@) Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude do� <br /> Q Hauler Q Inr� <br /> [ttttt:L <br /> Q Inactive Q Truck , <br /> Longitude – Q Planned Q'OTR Q End-Use Q Container <br /> - - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Re treader C) Dismantler Q Tire Derived Fuel <br /> Q Used Tiire 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> FV_7_A_ <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q l 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 /> I <br /> Q i Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> Q Q 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT <br /> Q I Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years _ – <br /> I <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 j 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 /> —---4= I <br /> Tell n -7 <br /> r7 4 <br /> Inspection Form Included: Q <br /> Comments Included 9 _ ?. r- Ins e ton s Si nature / !Phone N�ben <br /> Business Reps Slg�� Ph6ne Number _ P _– __- , <br /> 62081 <br /> INSTRUCTIONS ON BACK i Correct:* Incorrect: i �, .r P 3 <br /> e - __ - _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ . <br /> I <br /> i <br />