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Inspection Report Number <br /> Waste Tire Su 3.y & Inspection Report <br /> State B California Il - 1088493 <br /> CIWMB 181(New Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q _ �+, � Inspection Type (Fill one) <br /> Site Suffix: lJ Q Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB ® Complaint Q Educational Visit Q Other <br /> Businysica''ss, or Facility Name Inspected By Inspector <br /> �dress � — / Q <br /> I l <br /> Inspection Date <br /> Time to Time Out <br /> Business Rep Title o �J �j AM j� �) Q AM <br /> �/ ' V jq PM v v O PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (hole/PTE) /� Q (Fill one only) (Fill all that apply) (Fill all that apply) , (Fill all that apply) <br /> �f *Active Q Passenger Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q 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 ENFORCEMENT STATUS <br /> - ------------------------------------------- - <br /> V_i A HAULING AND MANIFEST REQUIREMENTS <br /> --- Notice Of Violation Q Extension <br /> Q QPRC§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 /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB 0 III���III /// III <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 f 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 /> / riS?Jti ('A G� CU�'YI v� `� r►� <br /> Inspection Form Included: <br /> Comments Included: ® ----- _ � �vt�Q-- — .-.._--- ---- —y <br /> Business Rep's ture Phone Number I pector's Signature Phone Numbcf <br /> 62081 - <br /> INSTRUCTIONS ON BACK ''t E +�' P I 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />