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® Waste Tire 940y & Inspection RepCfenspection Report Number <br /> �l State of California <br /> CIWMB181 <br /> Waste <br /> eManag4) Survey Form - Page 1 I1 - 1141340 <br /> California Integrated Waste Management Board <br /> Part_A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 5 a O O I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n O, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B Inspector <br /> P Y <br /> Phy/ s cad 1 d rOess S1 / 0 1v� <br /> Al Aram b '�'; <br /> q5_37,6 Inspection Date � ( U <br /> C1 Time In Time Out (, <br /> Business Rep Title JS AM <br /> ] AM <br /> > <br /> rn�5 / 0 • CRS 0 P ' / 0 P <br /> P YP <br /> - - - - - — - <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ;3 Q <br /> ® Active ® Passenger ® Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 Q Notice Of Violation Q Extension <br /> --1— ------ –—_ -- - <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 i 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 <br /> In Compliance - No Violations <br /> QQ Other: §_ <br /> Comments <br /> Inspection Form Included: Q 11n Comments Included: * Business Rep's Signature Phone Number s ign urePhone Number <br /> INSTRUCTIONS ON BACK Correct ncorrect. ,q a 62081 <br /> t <br /> White Copy: IW y Yellow Copy:Operator Pink Copy:LEA - i <br />