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Waste Tire Su. ;y & Inspection ReporAinspection Report Number <br /> State B California Survey Form Page 1 I 1 - 1127610 <br /> CIWMB 181(New nage) Y g <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: It <br /> 1 I �_j G�� IS Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C / If Referral,choose referral type(Fill one) <br /> Identifier: + 1 �l�C���l�,► ( �.1 ) �C./ 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address — /T <br /> TLI <br /> i 11_c, ,�t_ <br /> L1 <br /> ..... , .__._..... .. ----r- <br /> Street I <br /> Inspection Date i i iC �c <br /> State ZIP Gude Time In Time Out <br /> � �...�_ 1 QBusiness Rep Title O AM 1:11 <br /> AM <br /> O PM O PML <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 /> � L�. --tt-- @ Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude , <br /> O 0 Closed 0 Altered <br /> .I 15 Hauler 0 Indoor <br /> p 0 Inactive 0 Truck <br /> Longitude — I� ( J I j 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 1@ Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> f <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: IA 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />