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RP Waste Tire Sm ., a,y & Inspection Report Inspection Report Number <br /> State B California Survey Form - Page 1 11 1127604 <br /> CIWMB 181(New nage) ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPID- j Inspection Type (Fill one) <br /> Site Suffix: ®16 <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local � ,� ��CIC�v� /G�r,' I� If Referral,choose referral type(Fill one) <br /> Identifier: `r' 1 YA ( T <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i <br /> Physical Addressr S <br /> f. .._ ...........- .-_:__.....__ %.__ .4-1_ . ___....4_!-A.1..-.(................_ ...._ �...,........._............ I C <br /> Strdei <br /> f, Inspection Date 7,, T j�/J._L�... .C1_.i.....l_.__j <br /> State?ZIP Code Time In Time Out <br /> Business Rep Titlei <br /> L, 0 A 0 A <br /> J 0 P I I <br /> DPM <br /> Operational Status Tire Type Business Role Storage Type <br /> �Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> .N— .M <br /> 4P Active Q Passenger Q Generator Q Outdoor <br /> (O Q Closed Q Altered <br /> Latitude <br /> �_..1 Q Hauler Q Indoor <br /> L11 L Q Inactive Q Truck._............ .... O <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 /> IQ Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 Q Other: <br /> Comments �ln <br /> Inspection Form Included. Q' <br /> Comments Included: Q, <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A�, /A,\/ 1 E X Ml P; L j E. 1 C 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © . <br />