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z Waste Tire Sui .dy & Inspection Report inspection Report Number <br /> rin State B California IBM I 1 - 1143558 <br /> CIWMB 181(New Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- - © I Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Locale— If Referral,choose referral type(Fill one) <br /> Identifier: J 00-1 <br /> � 'l I COU Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> f-r 0,A\r2 (- e <br /> Physical Address ) �� <br /> C A ����� Inspection Date 5 / Q 2 <br /> L ot�\ K J <br /> Time In Time Out <br /> Business Rep Title 0 O AM Q AM <br /> QPM 3 3 O aPM <br /> ------- -- -- - - - - - -- - Operational Status Tire Type Business Role Storage Type <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> f I* Active Q Passenger •Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler i Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <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 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 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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/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 /> o Uio`a - U���o V ( �ouc(1 • -- -- <br /> inspection Form Included: a �• C y <br /> p Q <br /> Comments Included. ®; - a �Q 3 <br /> Business ep's Signaturer1l Phone Number / 1 Inspe is Signature � hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect ( �/ E A A P f 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />