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C-1g16.10400?.S <br /> �= es- Waste Tire Survey & Inspection Report Inspection Report NumberStat _ <br /> �� CrW B 181(New I 1 108850_ 0 ' <br /> CIWMB 787(teManag). Survey Form - Page 1 <br /> California Integrated Waste Management Board - <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile -inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: I _ Routine Q Re-inspection Q Referral Q Observation <br /> Local `1— 1 (rn^ If Referral,choose referral type(Fill one) <br /> Identifier: J�,) Jot,�,n W Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> At1C�-fin - ' D I gn <br /> Physical Address _-1 <br /> Street <br /> F 1 <br /> \ Inspection Date I <br /> State Cf.-r- Time In Time Out <br /> Business Rep 1y� Title M — - -- {-�7 0 AM -- --I 0A <br /> ,1� `t�� (�, 1�1� L. '_�� ' � V 'OPM <br /> �� OPM <br /> J- . J.-. V� l1�R+ e- ' <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r t r 5 <br /> lb Active Passenger t® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Q Indoor <br /> Q inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer A 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 I I <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 Date <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 /> 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 C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ow Vo ,me;Jew r wr�� one.Mn��s�' eU cti 7, <br /> Inspection Form Included: <br /> Comments Included: Q � 3 _ <br /> B sin s Rep's nature Phone Number nsp tors Signature Phone Number <br /> INSTRUCTIONS ON BACK C rrect: Incorrect: .X A M PL E 1112 3 62081 <br /> White C y:CIW Yellow Copy Operator Pink Copy.LEA <br />