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Waste Tire Su�y & Inspection Report Inspection Report Number <br /> �eae: _ <br /> • State of California Survey Form - Page e 1 [Il 110 436California Inegrat d WaseeManagement Board -- �J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Alnspection Type (Fill one) <br /> Site Suffix: "1 $ �� EoI_ _l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: L��f��qm=wr\ �u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> \ Inspected By Inspector <br /> � <br /> P �hysical Address <br /> 1� ww�l <br /> ��o -ANO <br /> Street <br /> Inspection Date 1 LZI <br /> 10-19 <br /> S <br /> Cry State— ZIP Coo'o Time In Time <br /> Business Rep Title I G AM , j *AM <br /> f � I <br /> — ,—""S O -� O Operational Status .Tire Type Business Role Storage Type <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> qj Active Q Passenger O Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude . I Q End-Use ® Container <br /> Planned <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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and'End-Use Facility ENFO'`'RCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS S 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EXTJ <br /> ® 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/C-IWMB 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 Q In C-ompliance - No Violations <br /> Q .0 . Other: <br /> Comments - <br /> 1.Aa1_ <br /> Inspection Form Included: Q <br /> Comments Included: • j <br /> / - - _/__9— <br /> Business Rep's Sign ture Phone Number nsp tors Signature- Phone Number <br /> INSTRUCTIONS ON BACK C rrect: Incorrec#: E X A M P L E 1112 3 62081 <br /> White Ct <br /> CIW Yellow Copy:Operator Pink Copy:LEA <br />