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Inspection Report Number <br /> Waste Tire Su. „ay & Inspection Repo► _ p p' � <br /> State of California 11 - 1143679 <br /> CIWMB 181( e ) <br /> California Integrated WasttManagement <br /> Waste Management Board Survey Form - Page 1 <br /> Part A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 6 - Q • Routine Q Re-inspection Q Referral Q Observation <br /> Local /��' If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> --- <br /> Business or Facility Name u Inspected By Inspector <br /> 1 }l>�oYu� L rvt b� <br /> Physical Address 3 O l <br /> l Inspection Date / � <br /> CA I <br /> CU Time In C' Time Out <br /> Business Rep Title ]) , 10 AM s %AM <br /> -�,� S; / V O O PM [ 6 ' � C O 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 /> 7 0 •Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler i Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <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 I q I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments L <br /> See <br /> Inspectio7Form ncluded: QComncluded: - - <br /> iness Rep's Signature Phone Number AS to ' ignature Phone Number <br /> jr INSTRUCTIONS ON BACK Correct:IS Incorrect: XI Gf" V hti ; g 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />