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YR Waste Tire c ;y & Inspection Report Inspection Report Number <br /> i State of California <br /> CWMB <br /> 1steManage) Survey Form - Page 1 I1 - 1141216 <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: 5 L <br /> a Routine Q Re-inspection 0 Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: )f \ �(;C�C I►"L `�i in -� Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ( Cmcl f 3 _ <br /> :' <br /> l.__....: <br /> 11A................4(11 t i`..._....... C_.._............................_...........__........................._....................._.._._._................................. <br /> i <br /> Street 1 � <br /> 111 Inspection Date OEC, <br /> City —,` state ZIP Cade Time In Time Out <br /> Business Rep Title O AM i O AM <br /> O PM U c (QPM <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) <br /> I O Active 0 Passenger Q Generator Q Outdoor <br /> "o O Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other ` � ' RE( � )V't <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> PO6 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> 0 Q Other: § I <br /> Comments cc-v)e. C`? <br /> LceCj <br /> Inspection Form Included: Q <br /> Comments Included: Q ". <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> __ .......r....._... 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � i± X I A M,P f ' 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />