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— Waste Tire SL Bey & Inspection Repor. Inspection Report Number <br /> State of California I .� T <br /> CIWMB 181(New <br /> Manag) Survey Form - Page 1 1 0 1 11 5 0 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I Q 7r Gj (� ` Q Routine ® Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: ;OQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "l1 <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM _ 0 AM <br /> 0 PM 0 Z 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 /> ®Active # Passenger ® Generator *Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - ® End-Use Q Container <br /> Q Planned Q OTR <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 /> 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 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 Date m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q ® 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement 1_•'.' <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 <br /> ® In compliance No Violations <br /> Q Q Other: § <br /> Comments r�Dv- <br /> 1� lUl Vk- (-L2 k Abr, .Z L�L `s <br /> 'C VA,5 tri�A�- k­t,A, G'o L`ts-(Jt <br /> cO W fvv� v - <br /> Inspection Form Included: Qy -5_ �/ <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins ector's Sig re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M'P', L E 1 62081 <br /> 0 White Copy:CIWMB Yellow Copy Operator Pink Cony LEA .'' <br />