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Inspection Report Number <br /> Waste Tire Survey & Inspection Rep(*, tState <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1143710 <br /> CIWMB 181(New nage Y g <br /> California Integrated Waste Management Board `�' <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> II Business Profile Inspection Details <br /> I TPID- Inspection Type (Fill one) � <br /> Site Suffix: "1 J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier S 0MIA,1) Co url� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspect <br /> orr <br /> Physical Address <br /> \a,;ts E l7f anAi <br /> C <br /> ��� Inspection Date I I <br /> 3 <br /> Time In Time Out <br /> Business Rep Title 0 S �AM � AM <br /> C l h �n 1 r `' J S O PM S O PM <br /> owcx r S W � -- - - <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 1& Closed Q Altered Ii <br /> GPS Latitude Jt Q Hauler IA ! Q Indoor/A <br /> O Q Inactive Q Truck NJ� <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I - - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 41 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 - <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 /> 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 /> � <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 Iin Compliance - No Violations <br /> 010 Other: § <br /> Comments co-s 04a, <br /> i <br /> - �}o_UtO�CI�Ian pf-( (t 4S n (,_(ZntQrn. <br /> PIKU i A_c_SS. <br /> Inspection Form Included: Q <br /> Comments Included: Qi - - — - --- - - <br /> �o� 4G �31?g <br /> Business Rep's Signature Phone-Number lnspe or',Signature hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �,1 E A p � 1 , 2 3 62081 <br /> � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />