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Waste Tire Sur„ay & Inspection Report Inspection Report Number <br /> CIWMB81California <br /> CIWMB Form - Pa(�e 1 Il - 1143591 <br /> California Integrated Waste Management Board Y g <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ � IR <br /> nspection Type (Fill one) <br /> Site Suffix: ` ` Routine Q Re-inspection Q Referral Q Observation <br /> Local- - ���_1 If Referral,choose referral type(Fill one) <br /> Identifier: n t7U1�1�1 n p� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Add.L <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ((�� V Q 10 AM 1 0 ® AM <br /> VLI ocr 0. PM O PM <br /> - - - Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active • Passenger ® Generator lb Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 41 Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <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 FGl m <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IIENFORCEMENTSTATUS <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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 <br /> ears <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered <br /> 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments �,11'slall�—nS�a.L'{lOn { f'C()��1�c//�()n �f111 (��.(� _A+)nL <br /> Inspection Form Included: Q <br /> Comments Included:0 -- 1 <br /> Business Reps Signature Phone Number Ins -pec is nature one Number <br /> - - - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect 'Al J 62081 <br /> �._ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :LE <br />