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Waste Tire054by & Ins Inspection Rei Inspection Report Number <br /> ... p p <br /> State of California <br /> - CIWMB 181(New Survey Form - Page 1 11 1127594 <br /> California Integrated Waste Management Board _... _._ __.. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j_j <br /> Inspection Type (Fill one) <br /> } Site Suffix � � ! _ ti? i Routine Q Re-inspection Q Referral Q Observation <br /> Local (' I 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 /> ....... <br /> Physical Address <br /> r <br /> y <br /> ! ........ .. ...... . r�__��3_.._.���� . <br /> Inspection Date 1"1 C <br /> t xj. Zi � dw, Time In Time Out <br /> Business Rep Title l O AM0 Am <br /> - <br /> t <br /> L <br /> AAx <br /> } 0 PM r I P C O PM! _. <br /> . Operational Status Tice Type Business Role Storac n Type <br /> (Fill one only) (Fill allthatappl# (Fill all that apply) (Fill all liliappiy)', <br /> Tire Count (WholeCPT9 " IU <br /> (� Active Q P assanger Q Generator Q Outdoo, <br /> o <br /> Latitude <br /> ._..... ( ? <br /> Q Closed O Altered <br /> GPS <br /> Q Hauler Q Indoor L__ __1 ` _ Q Inactive O -truck.._... <br /> Longitude Q End-Use Q Contai <br /> n,rQ Planned OTR <br /> ,. <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 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 /> Q Notice Of Violation Q Extension <br /> Q Q 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 Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date111 / 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 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/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 Q in Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> I <br /> inspection form Included: Q <br /> Comments Included: C <br /> Business RepSign. .t;ire" Phone Number Inspector's Signatt:ro P irons Number <br /> 02081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: A i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />