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Waste Tire Su Ily & Inspection Report Inspection Report Number <br /> State B California Survey Form - Page 1 Il - 1140612 <br /> CIWMB 181(New nage) ry <br /> California Integrated Waste Management Board l�• <br /> Part A- Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i ` r - O Inspection Type (Fill one) <br /> Site Suffix: ® Routine O Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SLYt - � QCHP QCIWMB � Complaint Q Educational Visit <br /> Other <br /> Business or Facility Name <br /> Inspected B <br /> P Y Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title I _ 0 AM 0 AM <br /> ` Z U A PM ( d O 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' Q Active Q Passenger 0 Generator Q Outdoor <br /> 0 Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O <br /> Q Inactive O Truck <br /> Longitude — 0 Planned Q OTR O 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 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder O 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 /> 0 Notice Of Violation 0 Extension <br /> 0 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years — y <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 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 O In Compliance - No Violations <br /> 10 1 O Other: § - <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Sign ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: } i E 1 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C <br />