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:•E@9. <br /> Inspection Report Number <br /> Waste Tire Su y & Inspection Reporfi' <br /> State CIWMB California I 1 11412 8 7 <br /> Californialntegrat d,Was81 tJeManageew lmentBoard Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection D Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier:— sm UI J l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicalC�ress ` j Al& � <br /> 133 Til ;e Lew i-s 6r, l <br /> Inspection Date � � � <br /> �5�� <br /> [� Time In Time Out <br /> Business Repi Title��J AM 7 Q ! f Q AM <br /> 2 <br /> V E GPM s 7 SPM <br /> -- 1 - -- 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 /> `[y <br /> f ® Active ® Passenger ® Generator IIs Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 10 Indoor � <br /> Longitude 0 Q Inactive Q Truck <br /> Q End-Use Q containerQ Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader I® 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 Q Other <br /> - - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> ----- — Q Notice Of Violation Q Extension <br /> Q 1 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 1 PRC§42953-Contracts with Registered Waste Tire Haulers. ! Compliance Deadline <br /> Q i 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 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 Com (lance -"No,Vins <br /> olatio <br /> Q Q Other: § � P <br /> Comments <br /> Inspection Form Included: l - '� -- 2 ?,,#r#gnture <br /> 87 -Comments Included: Qsmess s Signature Phone Number Phone_Number <br /> - - - -- -- <br /> - — -- -- - ---62081 -- <br /> INSTRUCTIONS ON BACK ,[Correct Incorrect ,+ <br /> . E X "" I <br /> White Corry;CIWMB Yellow Copy-Operator Pink Copy:LEA <br />