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Waste Tire St ey & Inspection RepoInspection Report Number <br /> ■ "';jj State of CaliforniaC,WMB 181 T — ■ <br /> ew 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 y 1143525 <br /> Part A- Survey-- --_- _ — BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I a 1 I I O Routine ®Re-inspection Q Referral Q Observation <br /> Local ! If Referral,choose referral type(Fill one) <br /> Identifier: 'sCCI (_) )VA 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - - - - <br /> Business or Facility Name Inspected By Inspector <br /> LLC_ I l <br /> Physical Address <br /> Inspection Date <br /> CA q��� Time In Time Out <br /> 1 <br /> Business Rep Title ®AM ® AM <br /> r <br /> (�^� nemarl / Q ' 0 C) O PM O PM <br /> -- - — - -----�- -- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' •� �s^� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L/ 0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler ® Indoor <br /> O O Inactive ® Truck <br /> Longitude - 0 Planned Q OTR O End-Use Q Container <br /> - - - - - - - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> 1 V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or F_XT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> Inspection Form Included: <br /> 1�3-501 Dt'L• 3 <br /> Comments Included: - - - <br /> B:�ess Rep's Signature Phone Number I 6 's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect '! E X +� P L I � 62081 <br /> --— -- <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />