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Waste Tire Sul „dy & Inspection Repor. inspection Report Number . <br /> CIWMB81California <br /> (New 04104) Survey Form - Pa e 1 I 1 - 1140728 <br /> California Integrated Waste Management Board <br /> Part A-Survey - Inspection Details - - BLUE OR BLACK_INK PEN <br /> Business Profile P <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: C) <br /> ! t 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \.X,(�C��_ ���� If Referral,choose referral type(Fill one) <br /> Identifier: � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name \ Inspected By Inspector <br /> Physical Address 1 C t. OJ i'fLl <br /> `T©`-) C1ne rol)ee Z-r1 <br /> Inspection Date <br /> JJ JC 6 <br /> c� t�� Time In Time Out <br /> Business Rep Title O AM ,/ O AM <br /> • G ®PM Ll 00 PM <br /> tA_a)0�1he� er — Operational Status Tire Type Business Role Storage <br /> P yp — 9 Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> @ Active 0 Passenger ID Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0Hauler 1 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> i <br /> IV I A HAULING AND MANIFEST REQUIREMENTS <br /> ® Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration <br /> stration and Transport of Tires <br /> ® 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date j I / m <br /> /0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB I I I <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 in Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: ---- ---- --- � <br /> Business Rep's Signature Phone Number sWs� lgnature Phonekr6ber <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X Gfi � E { , 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:rL <br /> ® ■ <br />