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s = Waste Tire Su & Inspection Report 7spection Report Number <br /> >®® 1 <br /> State I3 California Survey rVe Form - Page 1 11 1127532 <br /> CIWMB 181(New nage) V � Y y g <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> FBusiness Profile Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' ® Routine Q Re-inspection 0 Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t_C '�n �C, O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> l� Inspected By Inspector <br /> Physical A� Aiko ress <br /> tib M,c7u-t-CA,�k- <br /> � <br /> (' Inspection Date��' ��� Time In Time Out l <br /> Business Rep Title O AM <br /> © G/ //. Q AM <br /> ' PM L7 46 PM <br /> - - — - -- - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 60 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ®Passenger 0 Generator Q Outdoor <br /> O Closed Q Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair Q Trucking Fleet O Government O Retreader O Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators f <br /> In Compliance - No Violations <br /> O O <br /> Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: <br /> the s Signature Phone Number Ins p Fignature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Corr t: correct: 'h/I P L E, 1 j 3 <br /> White Copy: J• ''e!low C.)off Operator Pink Copy:LEA <br /> 1 <br />