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t Inspection Report Number <br /> F11 <br /> Waste Tire Sulky & Inspection Report <br /> State of California Survey Form Page 11 - 1025806 <br /> CIWMB 1111(New 04104) <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 /> {I Site Suffix: > L t Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> inspected By Inspector <br /> `Physical Address <br /> Inspection Date ) <br /> Time In Time Out <br /> Business Rep Title 0AM Q AM <br /> Q PM Q PM <br /> d I Operational Status Tire Type Business Role 1 Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> f ®Active Q Passenger ; ®Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — O End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 Hau)er 0 Agriculture Q Shredder ® Other >I:-T� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ' ENFQRCEMENT_STATUS <br /> A HAULING AND MANIFEST REQUIREMENTS _. Q Notice Of Violation Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O OPRC§42953-Contracts with Registered Waste Tire Haulers. t:ompllanca Deadline <br /> O O I PRC§42956-Registration/Decal in Vehicle rn m <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> O O 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB i { 4 S 4(Required for NOV or EXT) <br /> l <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years 4 <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers ` Q fie*�4. !CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities y <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Other: § In Camp(I�tttoa1P:Violations <br /> Comments ',�A � v b- Z> <br /> ,Inspection Form Included: O <br /> Comments Included: ���r <br /> Business Rep's Signature ._ Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct. �lnaarrect: :( y (r h �ISI-lE ( 1 l3 62081 <br /> White Copy:C1W MB Y0ow Copy.Operator Pink Copy:LEA <br />