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dWaste Tire Sul. y & Inspection Report Zspection Report Number <br /> State of California <br /> CIWMB1811(New <br /> Mana a) Survey Form - Page 1 Il - 1127858 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ -_ BLUE OR BLACK INK PEN <br /> — --- ----- ----- <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> - / Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address ( a" /J <br /> Inspection Date Date C) l l <br /> Time In Time Out <br /> Business Rep Title / C O AM G ` 0 AM <br /> `� 0 PM 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 /> f ® Active Q Passenger 0 Generator Q Outdoor <br /> 0 Q Closed I Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) NIA <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 A !HAULING AND MANIFEST REQUIREMENTS - 0 Notice Of Violation Q Extension <br /> _ - --- -- <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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 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 0 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments J��1%ht�l�/t1� %�'!S►xl�L/Y`+ %S (�lf� (,}��p1 �aA� f-QC�'L�lYLg <br /> ^ a led <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E '; A,; 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />