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Waste Tire Sut .,dy & Inspection Report Inspection Report Number ■ <br /> CIWMB 81Survey Form - Page 1'(New 04104) Il - 1143781 <br /> Calfornia <br /> ifornialntegratedWaste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey_._ - <br /> Business Profile Inspection Details <br /> TPID- inspection Type ( on <br /> Site Suffix: Routine Re-inspection0Q Referral Q <br /> Observation <br /> LocalC C If Referral,choose referral type(Fill one) <br /> Identifier: A SCCgL 1 v t C E7l/)� r�--I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name lJ (( Inspected By Inspector <br /> Physic A dre�s `�rL6�C W� fC� <br /> — <br /> �� Inspection Date <br /> Time In Time Out L <br /> Business Rep <br /> ,�' Title O AM 1i r O AM <br /> 1e 7� i✓\ '', 0 PM f > 0 PM <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) Q ®Active ® Passenger ®Generator Q Outdoor <br /> - -- --- -- --- - -- -- O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ®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 OtherZ7h <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - . - -- -- .LING AND — - -- <br /> V A �HAUND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> QQ § <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 114 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 EXTJ <br /> 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 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 62-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 14 CCR§184In Compliance -' No Violations <br /> Q Q Other: § <br /> Comments l„ {IMS 6C-' /&kl e-C C)'I A <br /> 677?C elm <br /> Inspection Form Included: Q' ls ••1 5G Y <br /> 7 C` <br /> Comments Included: Q - �Signture <br /> Bu i ep's Phone Number In pe or Si ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( I (J�; �j E A L 62081 <br /> PI <br /> White Copy:CIWMB Yellow Copy:Operator Pink op . <br />