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Waste Tire Su4B$o Inspection Repor ' ction Report Number <br /> State California Survey Form - Page 1 11 - 1127528 8 <br /> 0 E <br /> CIWMBB 181(New ry <br /> California Integrated Waste Management Board <br /> Part A- Survey N__ <br /> BLUE OR BLACK INK PE <br /> �Business Profile Inspection Details <br /> TPID- J Inspection Type (Fill one) <br /> Site Suffix: 6 C) 3 LJ Q l Routine <br /> - - QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sclt I �t�� ©� i �/ - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physical Address - 1 0 <br /> �/1 p /� Inspection Date —7 / O <br /> AV' `1 �v` � D Time In l Time Out <br /> Business Rep Title 5 Q AM y Q AM <br /> 0 40 PM OPM <br /> �- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / Q , <br /> ® Active ®Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer IS 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-1 HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Qd W <br /> t <br /> i <br /> with R <br /> t <br /> t <br /> PRC§42953-Contracts wegsereaste Tire Haulers. <br /> I Compliance Deadline I� <br /> Q Q !PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> m m <br /> Q Q 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q � Q 114 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) ' <br /> Q Q 114 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 ®In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> — - `r <br /> - <br /> Inspection Form Included: Q / <br /> Comments Included: Q -- --- -- -- - �� -- - <br /> Busirt s ep's ature Phone Number I ct s ignature Phone Number <br /> - _ - <br /> INSTRUCTIONS ON BACK Cor ec ncorrect +� A p 62081 <br /> X <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />