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Waste Tire SuO & Inspection Report�oPpection Report Number <br /> y _ <br /> State of California <br /> ® CIWMB 181INew04104) Survey Form - Page 1 Il 10 8 8 4 6 8 <br /> California Integrated Waste Management Board BLUE OR BLACKINKPEN <br /> Part A- Su rve -- - <br /> -Busin-_ R100111 <br /> pp ik & Inspection Details <br /> TPID- '� I Inspection Type (Fill one) <br /> Site Suffix: (!' O. Routine 0 Re-inspection 0 Referral 0 Obseru, tion <br /> If Referral,choose referral type(Fill one) <br /> Identifier: 3C( o ^�o l(l n Co Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name IInspected- .- y `-WInspector <br /> \ B _ t� <br /> C <br /> Physical AddrelsStreet <br /> _ Inspection Date <br /> - �'State ZIP G'ode Time In Time Out <br /> Business Rep Title 1 O AM)T�cl OPMO O AM <br /> QhPM <br /> Operational <br /> ( p Status Tire Type yp Business Role Storage Type <br /> Fill one only) (Fill all that apply): (Fill all that apply) (Fill all that apply) <br /> T,�re Cank Whale/PTE ,, _ <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered (�,I <br /> GPS Latitude I { �uu Q Hauler Q Indoor <br /> ,� Q Inactive Q Truck <br /> Longitude – ^� 1 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 /> Service Station Hauler Agriculture Shredder Other / <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS- - <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> ro� � <br /> §42951 -Waste Tire Hauler Registration and Transport of Tires <br /> §42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> §42956-Registration/Decal in Vehicle <br /> CR§18459 -Responsible EntitiesComplying with Manifesting Requirements bate mCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q 1 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 I 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 /> t <br /> Comments <br /> r <br /> 3 <br /> , <br /> t <br /> 1 � <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signatures: Phone Number <br /> �r� / 62081 -. <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: "Y V A <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:I, A\` <br />