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=gig: Waste Tire Su :y & Inspection Report Inspection Report Number <br /> State of CaliforniaCIWMB 181 04104) <br /> California lntgratdWaseeManagement Board Survey Form - Page 1 I1 1140889 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` p 7 Inspection Type (Fill one) <br /> Site Suffix: ` 3 y o2 / T - ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c. ►/� <br /> 1 Q.CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> /4 lit S <br /> Physical Address 3 <br /> .,'2 So P4,0 Kc/ ; .2 3 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ! o 1 0 S <br /> 0 PM <br /> - - - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) t �( <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude O ® Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 00111 Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 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 ' AHAULING AND MANIFESTREQUIREMENTS <br /> ; Q <br /> Q Q I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Extension- i <br /> Q O 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 / FE <br /> Q 1 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CfWMB Enforcement <br /> QQ 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 4D In Compliance- No Violations <br /> 0 Q Other: § - <br /> Comments <br /> -- <br /> Inspection Form Included: Q <br /> Comments Included: - � C 0('� <br /> BusinessU'signatuire <br /> --WPhibne Number I spector's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct � ncx�rrect . 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />