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Inspection Report Number <br /> Waste Tire Sl. ,y & Inspection Repor <br /> State California Survey Form - Page 1 Il - 1127507 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> I Business Profile Inspection Details <br /> TPID- ` Inspection Type (Fill one) <br /> Site Suffix: 1 J J t7 C Q Routine i® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ` (�� �( � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date 1 l -7 / <br /> Time In Time Out <br /> Business Rep <br /> \ Title / I O AM Q AM <br /> Ho"( <br /> ( � V(�J�1�Y t .� C)-®PM � '� 7 0 PM <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 ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 Q Tire Derived Fuel <br /> QP 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 �FORCEMENT 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. I Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> iQ Q li 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m � m / 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 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/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 <br /> Q Q ®In Compliance - No Violations <br /> Other: § <br /> Comments <br /> Inspection Form Included: Q C 0;In <br /> Comments Included:® --- �-✓-�~ �� --- <br /> Business Rep's Signature Phone Number e o ' i at Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �; ;. X 'M 3 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />