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r <br /> _ . Inspection Report Number <br /> Waste Tire Sw wey & ins ecti®n Ro ®rtState fCalifornia <br /> ■ <br /> CIWMB 181(New <br /> California Integrated Waste Management Board <br /> Part A-Survey __ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' 0 l'� to Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: a r, ��, (OUJ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address.J JCQ" O <br /> A4i) <br /> g ��� Inspection Date / <br /> ��U L Time In Time Out <br /> Business Rep •3 Title I Q . Q Q AM PM 10 3 Q it PM <br /> it AM <br /> Ccrlo S F CLF I PVC.- QA-VA Cduu"cr <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 /> S Active S 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 Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body a 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 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 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 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 /> Q 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 1 ® In Compliance - No Violations <br /> Q Q Other: § _ 1 _-- ` L ` L -- <br /> Comments (� ,` __ � - `n 3 il�l7ci�ifll� w rrcA C xo4hi S CJ`Glc— ax�(k AC — <br /> CA <br /> Inspection Form Included: Q ( + - <br /> Comments Included:® --- <br /> 4 <br /> Busines Rep's Signrature - Phone Number nspe is gn ure 15hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: J EX M <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy L ® ■ <br />