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Waste Tire Su. Y p p& Inspection Re ort0inspection Report Number <br /> -gyiLai State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 I1 - 1088049 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- /� ) I Inspection Type (Fill one) <br /> Site Suffix: J �/ tJ f Q Routine Q Re-inspection Q Referral Q Observation <br /> Local f f �'+ [ If Referral,choose referral type(Fill one) <br /> Identifidr: C�1/, !, �- ( (' .t t•. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> f1J V I - <br /> ri <br /> Street <br /> Inspection Date <br /> 4D 0 01 <br /> , I Time In Time Out <br /> State/'�Z�P Code <br /> Business Rep'-l c'.� %r' C,,I( j I' Title-�'t' {. iJ r'Jl ( i V�I i} - ((, AM 0 AM <br /> � 0 PM Q PM <br /> t f J � (c mr� <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 /> i) Active Q Passenger I Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude � . Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) III <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 /> 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 MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / 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 /> Q Q 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 Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments � � � <br /> • C' HCl <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number -Inspectors Signature Phone Number <br /> T 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X s E X i A M I P I Ll E l 11 i 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />