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Waste Tire spy & Inspection Repo"Inspection Report Number ■ <br /> State of California CIWMB 181 eIl - 1143843 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey -- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - Q Inspection Type (Fill one) <br /> Site Suffix: O Routine Re-inspection Q Referral Q Observation <br /> Localovn If Referral,choose referral type(Fill one) <br /> Identifier: ��� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Q, <br /> Inspection Date <br /> Time In Time Out l <br /> Business Rep Title i AMa AM <br /> QPM / / 0 � QPM <br /> - - -- - - - - - - Operational Status Tire TypeBusiness Role Storage Type <br /> d (Fill one only) (Fill all that apply) (Fill all that ap <br /> Tire Count(Whole/PTE) ply) (Fill all that apply) <br /> ® Active • Passenger O Generator Q Outdoor <br /> D 0 Closed Q Altered <br /> GPS Latitude `Hauler Q Indoor <br /> O O Inactive O Truck <br /> Longitude — O Planned Q OTR O End-Use 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 O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler O 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 <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 7 / <br /> m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> I <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q O Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ukieSj11ij4'nV1eeu <br /> 7� <br /> e r igr tura Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect X X It 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />