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Waste Tire Sul, ay & Inspection Report Inspection Report Number ■ <br /> State B curve Form - Page e 1 <br /> CIWMB 181 Californiaf New 04104) Survey N N y g I 1 1127731 <br /> California Integrated Waste Management Board <br /> Part A-Sur_vey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- )) Inspection Type (Fill one) <br /> Site Suffix: l © C� 1 O L * Routine Q Re-inspection Q Referral Q Observation <br /> Local / � If Referral,choose referral type(Fill one) <br /> Identifier: �.1(� � C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C l� l�' ^rte C� _ <br /> Physical Address 1 (_ gm <br /> Inspection Date i �q <br /> CCS l <br /> Time In Time Out <br /> Business Rep Title O AM L L O AM <br /> PM 40 PM <br /> ►� AJ. lreA <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 ® 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 O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Government Q Retreader Q Dismantler Q 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 /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V F—Al HAULING AND MANIFEST REQUIREMENTS <br /> Q Q - Q Notice Of Violation Q Extension <br /> 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 M / m / 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 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q In Compliance - No Violations <br /> Q Q Other: § <br /> CommentsOle 1 y- <br /> Inspection Form Included: Q >/7 �� � -7 <br /> Comments Included: Q "1 ✓ --- <br /> _ _ mess Signature Phone Number Ins ctor ' natui Phone Number <br /> 62081 <br /> INSTRUCTIONS ON B CK Correct: Incorrect: <br /> X[A 111213 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :LEA ® ■ <br />