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■ :', WasteTire SInspection Reportort NumberAey & Inspection Repor <br /> State a <br /> I I Survey Form - Page 1 _ e <br /> , CIWMB 181 New 04104 � � 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profilef, Inspection Details <br /> -- - - -- - <br /> TPID- .- Inspection Type (Fill one) <br /> RE Site Suffix: / ,-,.i !, ® Routine Q 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 Facility Name 6T Inspected By Inspector <br /> Physical Addr — ,� � C ?-I.- l f <br /> Street Inspection Date IF0 / LzEl <br /> Cit � J `�4Z1C­o_df_3j Time In Time Out t l <br /> Gr,y Mate- In _... <br /> 0 AM <br /> Business Re <br /> p c Title �.. �.. O PM I T_ O PM <br /> - <br /> Operational Status Tire Type Business Role r Storage Type <br /> The COUnt (Whole/FTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger § Generator Q Outdoor <br /> O Q <br /> GPS EIETTFLI Q Hauler Q In <br /> door <br /> Latitude _. Closed Q Altered <br /> Q Inactive Q Truck <br /> Longitude Q Q I Q End-Use Q Container <br /> - BB Planned OTR <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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 Q In Compliance - No Violations <br /> Q Q Other: § ------ - <br /> _J <br /> Comments - , 1 <br /> 7c' <br /> P' n <br /> �;l . � f *� f = i/SGL %1/' =6tC`✓� _f�.fn� - ,1`} > ! T'.- <br /> Inspection Form Included: Q , <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number" <br /> 6208.1 - <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X I . 'A ?,0, -, d_ � 1 <br /> L_. _. <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />