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Waste Tire Sutey & Inspection Report Inspection Report Number <br /> £SI3 State of California <br /> ice CIWMB 181( e ) Survey Form - Page 1 I1 - 1141188 <br /> Californnia Integrated WasttManagement <br /> Waste Management Board __.._....."._ __. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Inspection Type (Fill one) <br /> Site Suffix: __..� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Locali CUl If Referral,choose referral type(Fill one) <br /> Identifier: J UQq n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - -- - <br /> Business or Facili Name inspected By Inspector <br /> �W 3 I iJG <br /> Physical Address --T �1 <br /> ...V._ -.`h...�.� __ <br /> C& 9S <br /> Inspection Date <br /> State- c 'de Time In Time Out <br /> Business Rep Title [ /1 f 0 AM Q AM <br /> 1 1 <br /> QPM OPM <br /> \1r I _........ <br /> s t O Business Role Storage Type <br /> erational Status Tire TYpe <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whale/PTE) ' I <br /> Active Q Passenger Generator Q Outdoor <br /> Latitude M_^«T O Q Closed Q Altered <br /> Latit <br /> GPS Q Hauler Q indoor <br /> —�— f — - 0 Inactive Q'Truck <br /> i ......... . O <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 /> 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 § Y q - <br /> 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ` >�vL <br /> 1 <br /> a � � 1 �� /- 4 ' r �• 1 ,5 � � � ',� i .�� rr 11 <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X r._ <br /> _._ 62081 <br /> � � XiA �;P Lf <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />