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s ; Waste Tire Su: �y & 'Inspection Report Number <br /> Inspection Report ■ <br /> sQ= State CIWMB California I 1 - 114 0 7 61 <br /> grated Waste <br /> eManage) SurveyForm - Page 1 <br /> California Integrated Waste Management Board J <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: %���.��ri Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> Physical Address /'tzr� G IJC?f <br /> Inspection Date <br /> C/ �s1ca <br /> Time In Time Out <br /> Business Rep Title ! 0 AM �1 0 AM <br /> �— I�G�G"�.! ® I ® PM CJ I J5 ® PM <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 Q Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 ®Otheri;Cj-rJ►nt.�t-,r� -IC+rf" <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility NFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 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 Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> e/�t' Grlf cU! <br /> Inspection Form Included: O ) <br /> Comments Included: 0 — - �,pe <br /> B Ines tep' natur Phone Number r's Signature Phone Number ' <br /> INSTRUCTIONS ON CK Correct Incorrect I } 62081 <br /> � A <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink 5K <br /> A <br />