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1M1111Waste Tire & Inspection Re� Inspection Report Number <br /> State of BCalifornia — <br /> Cgrated 1 teManage) Survey Form - Page 1 I 1 1091995 <br /> California Integrated Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ,� � � � � � - �../ � Inspection Type (Fill one) <br /> Site Suffix: Routine Re-inspection Referral <br /> ® Q P Q Q Observation <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier: �� Goy'rt (z� <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> � P Y Inspector <br /> Ph sic Iddress <br /> �` Crr � Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> � ��� <br /> OAM > /I 0 A <br /> I�- <br /> ( ' 5 ® PM _<S, I. 7 ®PM v� �i�s �r�ll �i�✓ — <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C! (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 7 Active Passenger Generator <br /> ® � 9 ® ® Outdoor <br /> O Q Closed 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) <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 Other ��✓� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FIENFORCEMENTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Datem / <br /> / 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q Q Other: § I <br /> ® P <br /> Comments - <br /> Pi - <br /> / G ' <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Bus ss Rep's Signature Phone mber s e r' Signature Phone Number <br /> INSTRUCTIONS ON BACK <br /> Correct: Incorrect: p 62081 <br /> ,. <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />