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Waste Tire Suf#& Inspection Reportsepection Report Number ■ <br /> =;o= State CIWMB California I 1 — 112 7 7 2 7 <br /> grated 1steManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board ! J <br /> Part A-Survey_ -_ BLUE_ OR R BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- � � D � Inspection Type (Fill one) <br /> Site Suffix: ` U ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� � V�� `�J,-, , If Referral,choose referral type(Fill one) <br /> Identifier: C� tom[ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name_` _ Inspected By Inspector <br /> Physical AIJhdvroueii l 1�1c� V �ZT�d ✓�'��V <br /> 15,2�)l N , <br /> Inspection Date o Q <br /> CC �y <br /> Time In Time Out <br /> Business Rep Title 7 O AM J 7 AM <br /> 40 PM 0 <br /> M&119 <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 I$ Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> PS Latitude Q indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® 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 / L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ( ENFORCEMENT STATUS <br /> ! HAULING AND MANIFEST REQUIREMENTS <br /> V A <br /> Q A PRC§42 - Q Notice Of Violation Q Extension <br /> 951 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 /> I <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q © /� y 7 <br /> Comments Included: - ( ` j �� <br /> Business ep' Signature Phone Number nsp c ignature Phone Number <br /> - - -_ <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X $ 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink VK <br />