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Waste Tire Survey & Inspection Report. Inspection Report Number � <br /> CIWMB California <br /> 181 1(Nw04104) Survey Form - Page 1 I 1 - 1143996 <br /> California Integrated Waste Management Board Y g <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I q 9 - L Inspection Type (Fill one) <br /> Site Suffix: l Q ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> -Tol Uk GoUl1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Identifier- s(� <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical ddress <br /> b 1 �Qn E�GOj <br /> 3ab <br /> �i f1 CA Inspection Date <br /> 7 Time In Time Out` �J <br /> Business Rep TitleM 1 O AM 0 Q AM <br /> 0 P � ,3 �/ QPM <br /> - -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> { <br /> Q Active Q Passenger I* Generator Q Outdoor <br /> D i Closed Q Altered <br /> GPS Latitude Q Hauler I, ® Indoor <br /> Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container . <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0-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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> M / M / m <br /> 010 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 <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments W SS G \�C—10 0e— SN— <br /> N-0 <br /> !No WA,S 0'r c r --&C(ya- <br /> Inspection Form Included: Q, <br /> Comments Included* `.'2U�� 51!�_ t ✓ - �� �.�o <br /> Business Rep's Signature t Phone Number Inspec 's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: ■ <br />