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® Waste Tire Sui ,y & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181 04104) <br /> I 1 - 114 0 9 4 8 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- 0 0 3 _ I Inspection Type (Fill one) <br /> Site Suffix: e Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: C—VAA "'1'i aXAA,-t y`, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name, . t_ /7 Inspected By Inspector <br /> Physical Address <br /> Inspection Date t 0 <br /> rcc c C44 ( 6 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> OWWAr QQ 1 .Z 3 © ® PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -0f 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 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 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments <br /> tole <br /> Inspection Form Included: 0 � —— — '--- -- -- ) — <br /> Comments Included: ---- _—. <br /> Business Re _ <br /> 's Signature Phone Number pector's Si nature <br /> P 9 9 Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X �S/ I (� ® 62081_ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y: <br />