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t�s <br /> Waste Tire S� & Inspection Report nspection Report Number <br /> i7I State B California Survey Form - Page 1 11 - 1127522 <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- Inspection Type (Fill one) <br /> Site Suffix: 16 [ O l ® Routine Q Re-inspection Q Referral O Observation <br /> Local eferral,choose referral type(Fill one) <br /> Identifier: 6©(„,/ OCHP <br /> Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> CCAS 1 l�,~, I <br /> Physical Address � � - � � l �� <br /> 6-18 Gn�� G t K� <br /> Inspection Date <br /> ���6� a aDal 0 l > g e <br /> Time In Time Out <br /> Business Rep Title * 'M_ <br /> AM Q AM <br /> L! D Q PM 2 O O PM <br /> - - - - - - - p Type Storage Type <br /> Operational Status Tire T e Business Role <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> S Active ® Passenger ® Generator ® Outdoor <br /> 0 O Closed O Altered <br /> GPS Latitude O Hauler Q Indoor j <br /> 0 O Inactive O Truck <br /> Longitude - O Planned O OTR O End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair O Trucking Fleet 0 Government 0 Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture O Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ' - - --- — -i O Notice Of Violation O 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. <br /> Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle f°L <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O 14 CCR§18459.1 Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> O O Other: § -- - - <br /> Comments 0S <br /> aR6--g1C' 46, I[otj f D ��VI49 - <br /> CC <br /> Inspection Form Included: <br /> P O; <br /> Comments Included. Q <br /> Business Rep's Signature v Phone Number I ct 's ignature Phone Number <br /> -- - - - — - - -- - - ---_ - - -- -I <br /> 62081 <br /> INSTRUCTIONS ON BACK or e� ncorrs:ct Ah�t F Lr 2 3 <br /> White opy:L#g Yellow Copy:Operator Pink Copy:LEA <br />