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Eit <br /> Waste Tire SL ley & Inspection Repor Inspection Report NumberState ■ <br /> CIWMI 181(New <br /> Survey Form Page 1 I 1 - 1143771 <br /> CIWMB 181(New 04104) Y <br /> California Integrated Waste Management Board <br /> PartA-Surve f BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CXR ` i✓ �('�,/f�i / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 0t - - <br /> Inspected By Inspector <br /> Physical Address <br /> Q. L LYJ <br /> C t ' Inspection Date / 7, / / 001 Time In Time Out <br /> Business Rep Title O AM 7 O AM <br /> A o rl'Ein o. c,c -- r tf,dl�I uy,) rO O PM J QPM <br /> - - Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger Q Generator O Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 4V Hauler Q Indoor <br /> O Q Inactive it Truck <br /> Longitude - Q Planned Q OTR Q 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 Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® 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 j <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 DCT) <br /> Q 0 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 /> iQ O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®i in Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 1ZS G/t- <br /> -- - --- ---h - -- <br /> Inspection Form Included: Q <br /> Comments Included: ® � � --u�U l- �7� <br /> RA e ep's Signature Phone Number I6Vgnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X A M L E 12 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cap :LE <br />