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Waste Tire `' a: iy & Inspection Rep . Inspection Report Number <br /> S=� State of California <br /> CWMB 1(New04104) Survey Form - Page 1 I 1 11412 5 9 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ __-- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` O <br /> - � _ 40 Routine Q Re-inspection Q Referral Q Observation I <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: U � '� ►r \ ��1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical ddress <br /> L/ c26 <br /> �!- I Inspection Date <br /> `--� � �"� Time In Time <br /> O <br /> ut <br /> Business Rep Title1 0 AM D AM <br /> VZ Q PM Z O PM <br /> - - -- O erational Status <br /> - - Tire p i Type I Business Role Storage Type <br /> Tire Count(Whole/PTE) / O (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply)', <br /> b ® Active ® Passenger ® Generator 411 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® Dismantler Q Tire Derived Fuel <br /> — <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 /> - -- _ _ .-._ - --- -- - — <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation O 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 ! / <br /> 14 CCR 184 <br /> 59 1 Tire Program ID Number from CIWMB <br /> Q � Q § 9 B m m m <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 t 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 /> Q I', Q j Other: § <br /> Comments " -> vG,'�- _ <br /> t <br /> Inspection Form Included: Q� �7_0 t�t.rnatr. <br /> Comments Included. -mess Rep's Signature Phone Number In Phone Number <br /> - -- - <br /> INSTRUCTIONS ON BACK Correct ,Incorrect 1, E'X kjp L E��1� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />