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Inspection Report Number <br /> � .. : Waste Tire S�re y & Inspection Repo- _ p p <br /> Bs. a.H State of California I w a r'c' ,4 .y ,� ■ <br /> CIWMB 181 New 04104 D - U <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey _ BLUE OR R BLACK INK PEN <br /> Business Profile- 4-J!T�T­ <br /> _. ____ _ -Inspection Details <br /> -TPID- iQ Inspection Type (Fill one) <br /> Site Suffix: 5 C7 OJ Q Routine t� Re-inspection 0 Referral Observation <br /> Local 4c- -1--) d <br /> If Referral,choose referral type(Fill one) <br /> Identifier. �C� (l (a C(G i.l 1 t l C+Ji.�C i} <br /> 1 Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physi al Address Lj <br /> Street <br /> n Inspection Date <br /> I C Q_ M O _ � '_State IP Code Time In J Time Out <br /> City State Z1f�Code Business Rep Title 0 AM <br /> LL-1 <br /> O PM � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE)` i (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> I& PassengerGenerator 0 Outdoor <br /> C 0 Closed Q Altered i (S <br /> GPS Latitude O Hauler 0 Indoor <br /> — -- 0 Inactive 0 Truck <br /> Longitude - � Planned OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENTSTATUS <br /> O ! Q HAULING <br /> R U§ NG AN\D MANIaste FEST <br /> Haule�`r Registration <br /> Transport of Tires 0 Notice Of Violation 0 Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date [I] / m / Ell <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ----- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 0 Other: § <br /> Comments -�—� - 1 <br /> C.t �I Lit S `�- ()c�)I r) <br /> ANrC. !F'e'r <br /> t- I, <br /> Inspection Form Included: <br /> Comments Included.- <br /> Business Reps Signature Phone Number In eCttS'r s Signature1 Phone Number <br /> - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> '�k 1 <br />