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Waste Tireftuy & Inspection Repo" Inspection <br /> pection Report Number <br /> State California <br /> CB181ee) Survey Form - Page 1 T1 114300 <br /> California Integrated Waste Management <br /> - <br /> Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �y O Inspection Type (Fill one) <br /> i Site Suffix: 1 b $ i Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: �Ll� 70,*#tjU)A CbLll1}� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> (0.-m4 r ct� L Ott'lsv;(,z <br /> Physical Address <br /> 6A 15gh Inspection Date 1 <br /> C\ Time In Time Out <br /> Business Rep Title I O AM <br /> O PM 5 V 0 PM <br /> _ �_- ov, K t�4�-o.. Perm\1\01 nr, - - - - <br /> - -- - - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) � � <br /> ®Active Q Passenger Generator Q Outdoor <br /> - -- - - - D O Closed Q Altered NIA <br /> GPS Latitude O Hauler Q Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - 0 Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) _ -— <br /> O New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O 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 1 HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O :14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> 0 0 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 Q 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 Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 0 (Other: § I <br /> 1 <br /> Comments_J\0 <br /> (Insp(Inspection <br /> ection Form Included: Q Comments Included: Qi Ars Busin s Rep's Signature Phone Number Insature Phone Number <br /> -7- 62081 <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: E X A P L T <br /> ■ _- - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink py: <br />