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jjWaste Tire Sui �y & Inspection Report Inspection Report Number <br /> State BCalifornia Survey Form - Page 1 I1 - 1140818 <br /> CIWMB 181(New nage) Y g <br /> California Integrated Waste Management Board `�J" <br /> Part A- Survey - BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q 4� Z © I® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: lsfwv- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `-� Inspected By - Inspector - - <br /> Physical Address <br /> �vevf�uti <br /> 5 © i P Rd ;2- <br /> Inspection Date t ;2, 3 <br /> C0� <br /> Time In Time Out <br /> Business Rep Title / AM ® AM <br /> / D . 3 Q 0 PM S ` 0 PM <br /> - f Operational Status� (ire Type Business Role <br /> Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) Fill all that apply) (Fillall that apply) <br /> (Fill all that apply) <br /> ® Active ® Passenger Q Generator ® Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use I* 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 ENFORCEMENT STATUS <br /> --- ------ --- —......_ <br /> V 1 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 /> — <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle j <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 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 $" u <br /> � In �a�ipl��rt� � No Yl�alatipns <br /> Q Q <br /> Other: § <br /> Comments <br /> Inspection Form Included: s r <br /> Comments Included: <br /> Business Rep's Si ure Phone Number spec or's Si nature �Z Ph �Numbe�L <br /> p g <br /> INSTRUCTIONS ON BACK k Correct. Nn�orrct , ' t J� 62os1 <br /> _ X 1 23 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />