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Waste Tire Su.. %y & Inspection Report Inspection Report Number <br /> Stateof CaliforniaCIWMB 181 I 1 - 1140555 <br /> California Integrated Wast(New <br /> Management Board Survey Form - Page 1 <br /> PartA- Survey BLUE OR BLACK INKPEN <br /> Business Profile Inspection Details <br /> TPID- z O `• _ © / Inspection Type (Fill one) <br /> Site Suffix: �d 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `� ��y- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 11 / 3 - 1 o /�d, <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title / O AM / 0 AM <br /> i _ 0 PM O i d ® 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 /> ®Active 0 Passenger • Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other s1 �.LC�rrt� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments <br /> .lr VC 1 e4okA,— <br /> dlti 4 5. dgt,4_IE cL v�ta <br /> Inspection Form Included: _� <br /> p O zoo '168-oka-� <br /> Business Reps Si nature h e Number nspector's nature Phone Number <br /> Comments Included: <br /> INSTRUCTIONS ON BACK Correct: Incorrect: w X A M 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co ■ <br />