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Waste Tire Orrvey p p& Inspection Repivot l Inspection Report Number <br /> State of California <br /> CIWMB 181 I 1 - 114 3 7 2 3 <br /> California In egrat d Was WasteManagementBoard Survey Form - Page 1 <br /> Part A- Survey_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - -- "7 _ I Inspection Type (Fill one) - - - <br /> Site Suffix: $ a. Q Routine ® Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(,� J o� 6��n un u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - - J <br /> Business or Facility Name <br /> Inspected By Inspector <br /> MOLka4'% O \)CMQ� eYp[ef,'.. <br /> Physical Address &n ESI!V l W <br /> Iblq �,s51�m�r Avg- p <br /> Inspection Date <br /> H l� Time In 1V Time Out <br /> BusineTI0 AM <br /> PRep t� h h 1 1, ® AM CoC f_ m5 ' V V O PM _1 O PM <br /> �Gn SUVI Z.� Vile oj'_bln� -- <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 /> f ' <br /> *,Active Q Passenger ® Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive i Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <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 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 A HAULING AND MANIFEST REQUIREMENTS <br /> ® 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 /> FN / <br /> / Pol <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 /> I <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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments TQ- bUIS 10S% -`— `� l� ] ��1<j iQi1 � QA 01'\ <br /> ,8xr tt�o <br /> ,Inspection Form Included: Q / R <br /> Comments Included: - L'l 1 <br /> usiness p s Signature Phone Number Inspe or's Signature Phone Number <br /> - - - - -- I - <br /> �'� 11 '12T3] <br /> �� 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect !�i � � � fl hN P 1� �' P � � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />