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Waste Tire SL - ey & Inspection Repor, Inspection Report Number ■ <br /> State California I 1 - 1127946 <br /> CIWMBB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> 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: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: V � -✓ Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Al, qvtD Q 3 lmc�>�; e r _ <br /> Physical Address fD <br /> -1 <br /> � tCk <br /> Inspection Date 0 (" <br /> } <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> l 3 0 P c QPM <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 O Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 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 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 Notice Of Violation <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Q Extension <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 -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 EX7) <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 Q Referred/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 Generators16 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> - ---- f - rn ynrv � -- - <br /> Inspection Form Included: Q� ) <br /> Comments Included: l�167.� <br /> - - <br /> usi ess Rep's Signature Phone Number Ir1sp or's i n ture Phone Number <br /> .... ._. �..... • _ <br /> F�L <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect. X "� l � M F �. , 1� 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy L © ■ <br />