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Waste Tire Su :y & Inspection Report Inspection Report Number <br /> SB�II, State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I1 - 1141217 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile (inspection Details <br /> TPID- Z I 2 / Inspection Type (Fill one) } <br /> Site Suffix: , ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ro !��j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _ 1 i Glns% t Gl 11 t J l <br /> Physical Address 1 ---� ' G <br /> ` L _............... _. _.._._ _.. ___.____..........I <br /> ........................_.....:...C.�.....v...�,.�......__... _ .... �._ Inspection Date i` <br /> 10:L� I! <br /> �t�G6 I <br /> S?ate zip Co Time In Time Out <br /> Business Rep Title _._. _.._.__ <br /> 4 AM 0 AM <br /> Q PM O PM <br /> x <br /> I 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 /> Active Q Passenger Q Generator a Outdoor <br /> � Q Closed Q Altered <br /> GP$ Latitude � j •i ��L 1 Q Hauler Q Indoor <br /> _.._ O 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 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 Notice Of Violation Q 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 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments ? <br /> � (��\,_���1 <br /> Y, (-,jr( Q it-4 L� - - - <br /> �l0 , IS --oar Ayra s. C4 60yVe r✓1 <br /> Inspection Form Included: Q <br /> Business Rep's Sign <br /> Comments Included: Q t - - <br /> nature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X X A h�j E 1- <br /> Z <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />