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.... <br /> Waste Tire SL iy & Inspection Repor, Inspection Report Number <br /> State California Survey Form - Page 1 Il - 1127549 <br /> CIWMBB 181(New <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: ( (3 ® Routine Q Re-inspection G Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �(�� � �� CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �Tes �v 3 cj '� <br /> Physical Address - l G k bj�_ <br /> Inspection Date ! <br /> ) 3 <br /> 1. <br /> Time In Time Out <br /> Business Rep Title l 0 AM Q AM <br /> \ L �� 0 PM t 3 7 ® PM <br /> - - - -- - - Operational Status j 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) <br /> f ® Active Passenger (6 Generator ®Outdoor <br /> O G Closed 0Altered <br /> GPS Latitude G Hauler G Indoor <br /> o G Inactive G Truck <br /> Longitude - G Planned 0 OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler G Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station G Hauler G Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - — -- <br /> V A HAULING AND MANIFEST REQUIREMENTS ®I Notice Of Violation Q Extension <br /> G G PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> G G PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> G 1 G PRC§42956-Registration/Decal in Vehicle I�C� <br /> G G 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> G Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> G G 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> G G 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> G G 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> G G 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> G G 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> ® G Other: § 4F+.SIG �s �' <br /> Comments <br /> �mr (�A _ - <br /> (J <br /> Inspection FormIncluded: (D a.O� -�� (5 © � •_````//q �-'/// <br /> Comments Included: - - --- -- `- C4 , <br /> Business Rep's Signature Phone Number In pe or's i ature Phone Number <br /> - -- 62081 <br /> INSTRUCTIONS ON BACK Correct:l� Incorrect: X ,. �/; E�Xl AhsP I lr I El 1112 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />