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Waste Tire Sui - Ziy & Inspection Report Inspection Report NumberState ■ <br /> CIWMB <br /> 181(NewCaliforniSurveyForm - Page 1 <br /> � CIWMB 187(New 04104) g Il 1143638 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile 'Inspection Details <br /> TPID- � � O ryr � � � � � � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local { `^ If Referral,choose referral type(Fill one) <br /> Identifier: ��' ' l.Ar lC/�i`1 t// Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By Inspector <br /> t <br /> Physical ress <br /> 3 c7 All A,. <br /> Z;r1- <br /> Inspection Date Z <br /> � � ip 6 C✓ <br /> Time In Time Out <br /> Business Rep Title �AM AM <br /> O PM <br /> 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 O Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR End Use ® Container <br /> --- -------- <br /> Business Type (Fill all that apply) — <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer 0 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 i A i HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 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 /> O O - ----- <br /> 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 /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> � <br /> Comments Included: <br /> Business Rep's Si nature Phone Number In p t is ign ure Phone Number <br /> INSTRUCTIONS ON BACK :Correct_0 Incorrect: A X A p` L I 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy:L ® ■ <br />