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Waste Tire Sfty & Inspection Repo" <br /> lnspection Report Number ■ <br /> Ifi CIWMState B <br /> 181(New <br /> Survey Form - Page 1 I 1 - 1140594 <br /> CIWMB 187(New nage y ('� <br /> California Integrated Waste Management Board `�' <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> - ---- - ti ;t - - -- <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type Fill one) <br /> Site Suffix: 1 a O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> � <br /> Identifier: (,k n J O kJ L4 i j) Cf',,�n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S 5A to �as pus � 5 - � d � <br /> Physical Address ;cn <br /> � J �IMJ1Q Inspection Date <br /> �GIG <br /> A o�12k CA <br /> Time In Time Out <br /> Business Rep Title/ - O AMO AM <br /> 0 PM - —� O PM <br /> - - - U 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> D ® Closed Q Altered N <br /> GPS Latitude i N 1 Q Hauler Q Indoo A <br /> D Q Inactive Q Truck/ R <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 /> '_LI 1tity^ Cen�c <br /> Q Service Station Q Hauler Q Agriculture Q Shredder (P Other D 17f!i 1 r <br /> i <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility : ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> V AQ Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> - QQ 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 �j' 041 <br /> �bktowlll UN4 n <br /> Ahon <br /> Inspection Form Included: Q <br /> 0 <br /> Comments Included: [9 '"-'�"� ' 4&1(7 <br /> -_ <br /> Business Re 's ignature Phone Number �Ine�r'sSign.tu�re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corre :: Incorrect: X �/; � A hl4 P! L 111 Z 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />