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Waste Tire Su. „ay & Inspection Report Inspection Report Number ■ <br /> !"Z CIWMof California <br /> B 81(New 04104) Survey Form - Page 1 Il - 1140778 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � � r Inspection Type (Fill one) <br /> Site Suffix: J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ((�� L If Referral,choose referral type(Fill one) <br /> Identifier: n�� 1 n W u n-[ — CHP Q CIWMBQ Complaint Educational Visit Other <br /> Business or Facility Name Inspected By Inspector <br /> �A <br /> Physlchgess I l <br /> Inspection Date � � � rD ( / <br /> l Time In Time Out <br /> Business Rep 1 Title O AM O AM <br /> PM U PM <br /> sof - - -- --- - —-- - <br /> - Operational Status Tire Type Business Role Storage Type <br /> !� n <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � d o-1` <br /> • Active Q Passenger 0 Generator J$ Outdoor <br /> 0 Q Closed 1 0 Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> O Q Inactive * Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Trucking Fleet-0—Government O Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND—MANIFES-T REQUIREMENTS <br /> Q Notice Of Violation 0 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. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 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 /> - <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> A In Compliance - No Violations <br /> Q 1 O Other: § <br /> Comments - 1Y bQAO <br /> 61�(, ,1e�6 ----- <br /> Inspection Form Included: 0, <br /> Comments Included: b �f �_!___ �Q `1t0 <br /> B$, , ess esaS�ignat.r. Phone Number Inspecs ignat a PlSone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect I y `"h X A A P �; I z � 62081 <br /> --- ------ t-' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C p . A <br />