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Waste Tire Su ;y Inspection Report Inspection Report Number <br /> �fi9 <br /> State of Survey Form - Page 1 I1 - 1141318 <br /> CIWMBB181(New 04104) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey _- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: J V�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> l� a <br /> Physical 9ddr s t G — 1 <br /> Inspection Date 1 O Q GJ <br /> Time In Time Out <br /> Business Rep Title 0AM /� 0 AM <br /> I <br /> 3 : 3 00 PM 1 � 41 0 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 /> 0 Active 0 Passenger 0 Generator ® Outdoor <br /> 0 Q Closed � Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I <br /> 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_A HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 1 Date m / m / F11 <br /> 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 O - - <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 j Q Referred 1 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 h0 (0 e Mspf-cb <br /> 'Inspection Form Included: Q �� / G <br /> � ji !D G <br /> Comments Included: Q � 'G6 <br /> Bu inesCSL7 <br /> s Rep's ignature Phone Number In a tor's ig ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co rec Incorre0: <br /> Iwo Yvhite Copy „Fl r�riow aior ..;p;' �:-.' <br />