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t � Waste Tire Sy & Inspection Repor' Inspection Report Number <br /> State of California <br /> CIWMB 781(New 04 <br /> California Integrated Waste Management Board urvey Form - Page 1 Il 1140644 <br /> Part - Survey <br /> usinass Profile BLUE OR BLACK INK PEN <br /> Part------ — <br /> - <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: � (J( y S 3 2 - C <br /> ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local <br /> Identifier: If Referral,choose referral type(Fill one) <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physica�d�s inrr!LCr/7!'C-S — - - - ---- <br /> j ,_ ✓ Inspection Date ` Q / f7 / Q <br /> Business Rep Time In Time Out <br /> Title Q AM Q AM <br /> �4✓,`n l <br /> ® PM ® PM <br /> ✓ - I Operational Status Tire Type Business Role Storage T <br /> ` <br /> Tire Count (Whole/PTE) Fill one onl l ype( y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> s � <br /> _ ®Active 0 Passenger 1 0 Generator ® Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> Longitude _ <br /> 0 0 Inactive 0 Truck <br /> - - <br /> Q Planned 0 OTR 0 End-Use Container <br /> Business Type (Fill all that apply) - - - <br /> - - -- <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government Retreader <br /> 0 Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 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 /> 1 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires V - 0 Notice Of Violation 0 Extension <br /> 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 PRC§42956-Registration/Decal in Vehicle Compliance Deadline <br /> i <br /> 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Date / <br /> g Number from CIWMB m <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 i 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years - -- <br /> LOO <br /> L <br /> 0.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!CIWMB Enforcement <br /> 1 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 2-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> Comments <br /> Ja IIG11t�It•,�,� <br /> Inspection Form Included: 0� <br /> Comments Included: 01 <br /> -- - - ---C <br /> _ I Business Rep's Signature -- <br /> — - - - P 9 Phone Number Inspector's Signat e <br /> P one Number <br /> INSTRUCTIONS ON BACK Corr . Incorrect: X j ( A p 62081 <br /> White Copy:C WMB Yellow Copy:Operator Pink Co y:LE <br />