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Inspection Report Number <br /> Waste Tire vult vey & Inspection Repay ■ <br /> CIWMate B <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1143808 <br /> CIWMB 181 thew 04104) Y g <br /> California Integrated Waste Management Board "�' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: ` r_ r,, - - - -- <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Say (1 CQuQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Qe <br /> Physical Address <br /> i 1 i <br /> Seo Inspection Date <br /> Time In Time Out� 1 <br /> Business Rep Title 5 O AM /, Q AM <br /> v JUI law` u J- PM a 3 v (V PM <br /> u- - ` M_5 - — <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) id <br /> ®Active •Passenger •Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned If 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 Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber /� 1 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other V 4il /A <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 <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 I <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 (e In Compliance - No Violations <br /> 1010 Other: § <br /> Comments D9y40fM9A C —ti-'-ti 1t `^tet 1It I <br /> �o <br /> Inspection Form Included: Q (a <br /> Comments Included: Q ���� "=W - `_` ���g_31-4— <br /> Business Rep's Signature Phone Number Inspec is Si ure Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: EXAM 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE <br />