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:=Enspection Report Number <br /> F! Waste Tire Su& & Inspection ReporL <br /> LNLNCIWMB <br /> of California <br /> CIWMB 181( e ) Survey Form - Page 1 1 6 0 3 3 $ a <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I -35 -1 frj © Q Routine I* Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Ph cal Address <br /> � <br /> Y-0 Z <br /> Inspection Date Time In Time Out <br /> Business Rep Title _ O AM Q AM <br /> O PM O 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 /> Active ®Passenger ® Generator ® Outdoor <br /> '\ O Q Closed Q Altered <br /> GPS Latitude )J \� Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude – ` Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® 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 ENFOR61MENT STATUS <br /> O;3,Q, EQUIREMENTS – Q Notice Of Violation Q Extension <br /> r I <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 ® In Compliance - No Violations <br /> 10 1Q Other: § – 1 <br /> Comments ���1©t,..� T� L' _-QY <br /> C- p <br /> q ?�S_C� T f•-.�./S� I <br /> dO <br /> 1.15 J –I/"i'v�S 'Tic,t•– 1_S _ �._4w I'47 r <br /> Inspection Form Included: Q �� <br /> Comments Included:® (� l>— <br /> Business Rep's Signature Phone Number s ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK E X A F L 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />