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MWaste Tire Su. y & Inspection Report nspection Report Number ■ <br /> ij <br /> StateB CaliforniaI1 - 1140853 <br /> ra CIWMB181(New nage) 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 , 1 - Inspection Type (Fill one) <br /> Site Suffix: `7 �� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> �G+/1/'1 •Ctu, , „ �� r� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J -- - - - -- <br /> Inspected By Inspector <br /> Physical Address _ - (� 0�� <br /> 3S3_2 /'elf ✓�e . - - - -- <br /> Inspection Date © j / f 3 / <br /> (-A � �10� <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O ® PM 30 ® PM <br /> 14csk, Af� ver -� e7w v -- r - — <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> f Z ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <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 ® Dismantler 6-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 /> i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> _........_ ._._ _-:._.. <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 /> Q14 CCR§ 18459 -Responsible Entities Complyingwith Manifesting Requirements <br /> Date / / <br /> m <br /> Q Q 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 /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers .Q Referre _,1 CJ1'WMB_Enforcement, <br /> Q Q 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 <br /> Q I 0 In Compliance No Violations <br /> Q Q1 Other: <br /> Comments <br /> Inspection Form Included: 0 <br /> X �z0-C? 40,ig__C62� <br /> Comments Included: - - ---- - - -- - - - - - - <br /> Business Rep's Si ture Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect. X'`� N6 I X I A'M P I L I E I I 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />