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Waste Tire S y & Inspection Repoonnspection Report Number ■ <br /> State of California I 1 - 1143513 <br /> CIWMB181(New 04104) SurveyForm e 1 <br /> California Integrated Waste Management Board - Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Ins <br /> -- _. - <br /> Business Profile pection Details <br /> TPID- Inspection <br /> Inspection Type (Fill one) <br /> Site Suffix: 5 79 ® 4, 0 [ 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local • j-� If Referral,choose referral type(Fill one) <br /> Identifier: sl.►\ ` ��_J t` ` `-`'�" ` ' `-'1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -- l <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ass <br /> Inspection Date © l Q <br /> Time In Time Out <br /> Business Rep Title AM AM <br /> f ' O o PM PM <br /> OCtLne Y — -- --- <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) �� ® Active ® Passenger ®)Generator Outdoor <br /> Q Closed Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 I ENFORCEMENT STATUS <br /> V A I 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 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 /> QQ I Q !14 CCR§18459.3-Retention of Comprehensive Trip Logs <br /> 14 CCR§18460.2-Manifest System Requirements for Reg Registered Waste Tire Haulers <br /> II <br /> Q Referred/CIWMB Enforcement <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q _. - -- <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: t✓ ! ��� — - — <br /> p -- _ <br /> Comments Included: ` V�� <br /> Business Rep's Signatu a Phone Number I r' gnature Phone Number <br /> -- - - l 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X� V) JI � E <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />