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Waste Tire Sui - 4.-%Vy & Inspection Report Inspection Report Number <br /> State <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1143632 <br /> CIWMB 181(New 1nage) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey - _- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O ( Inspection Type (Fill one) - - --- -- <br /> Site Suffix: ( " 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 61 1A1 1) lcUv1ll 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 11�(Am S flop 6L of_ <br /> 3 _ /� n� <br /> Physical Address t V ( '�' 1 E5 <br /> iq �l mwq j �VVCA, J <br /> rr`` <br /> C <br /> Inspection Date 3 '"1 / l O <br /> (A �� GA �� � Time In Time Outl <br /> Business Rep Title 0 AM 2 S Q AM <br /> \ SOUI • PM J O J 0 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 /> AActiveg•E GLPassenger ® Generator O Outdoor <br /> Latitude <br /> 0 O Closed Q Altered NIA <br /> GPS Q Hauler Q Indoor <br /> O ® Inactive ® Truck <br /> Longitude — O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair 0 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 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 <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <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 /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / m / m <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O -- - - -- <br /> 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 10 In Compliance - No Violations <br /> O Q Other: § <br /> Comments (� � � 1 � iSAk APe1�nK etc nv�— <br /> MIA 1AU51003dLi. <br /> Inspection Form Included: q - <br /> Comments Included: � - -- — - - <br /> Busip(e Reps Signature _ Phone NumberIns, tor's Signat a Phone Number <br /> INSTRUCTIONS ON B K i Correct: Incorrect: A IL 1 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: ® ■ <br />