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jjNaste Tire S__. . ay & Inspection Repo. _ Inspection Report Number ■ <br /> State B CaliforniaCIMI 1w 04/04) - 1127677 <br /> California Integrated Waste 181 eManagement Board Survey Form - Page 1 <br /> Part A-Survey__- BLUE OR BLACK INK PEN <br /> Business Profile [Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: O ` _ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �1 �� �lJ! V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A I �� v - ;� <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out `J <br /> Business Rep Title 2 f� 0 AM � Q AM <br /> V V s PM ✓ 0 PM <br /> L;cj'h ' nth alk M&R - - - <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 /> ® Active Passenger Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader 0 Dismantler O Tire Derived Fuel <br /> 0 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 /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A AU <br /> HLING AND MANIFEST REQUIREMENTS <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 F_X7) <br /> O O 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 /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> 10 1 0 1 Other: § <br /> Comments �N ,• <br /> a�c� LOLL, jun- (-06- V --- -- <br /> Al D <br /> Inspection Form Included: <br /> —�C �0_ i 773' <br /> omments Included: t eRe� Signature Phoh mb lnsp c or naPhone Number <br /> .. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I Al It <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop L ® ■ <br />