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® Inspection Report Number <br /> Waste Tire SL . :y & Inspection Repos <br /> State of California Il - 1143526 <br /> CIWMB18l(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , l • Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: Cti� a ��v�� �✓vn�''( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �.�5� 3 � - l C) i A t�o �1m�1 <br /> Physical Address c <br /> Inspection Date -7 ciCA I <br /> Time In Time Out <br /> Business Rep Title ®AM O AM <br /> l ' 9 Q 0 PM Z O 0 PM <br /> - <br /> - Operational Status Tire Type Business Role Storage Type <br /> Fill one only) Fill all that apply) Fill all that apply) Fill all that a <br /> Tire Count(Whole/PTE) (� ( ( pp y) ( pp y) ( ppI y) <br /> f f v o Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed ®Altered <br /> GPS Latitude O Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude - ®OTR O End Use Q Container <br /> O Planned <br /> Business Type (Fill all that apply) <br /> 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 /> -- --- - — - <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 /> j Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 10 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 10 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 10 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 1010 Other: § <br /> Comments C <br /> Inspection Form Included: 01 <br /> Comments Included. ®I QU ( <br /> I�.73 <br /> Business Rep's Si ature Phone Number Ins br'� i ature Phone Number <br /> -- --- - - - - - --I <br /> INSTRUCTIONS ON BACK I Correct: Incorrect X J �/! J �' �{ r� Nt � L � f 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />