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a,•'yl t Waste Tire : ,%y & Inspection Repo Inspection Report Number <br /> State CIWMB California <br /> 181 I 1 - 11412 6 0 <br /> Californialntegrat dWastJeManagementBoard 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: 3 I46 Routine Q Re-inspection Q Referral Q Observation <br /> Local `^ If Referral,choose referral type(Fill one) <br /> Identifier: �Q' l 1 C <br /> f ,�d � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - --- - `Je- V--- - - - <br /> Business or Facility Name - <br /> Q {� / Inspected By Inspector <br /> Physical Address C� 1 <br /> Inspection Date � � �1 ( � C) <br /> Cj <br /> Time In Time Out <br /> Business Rep Title f L/ O AM / Q AM <br /> 1 ( ® PM V J ® PM <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f t✓ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L ®Active Q Passenger O Generator Outdoor <br /> 0 Q Closed ' Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 49 Truck <br /> Longitude - Q Planned Q OTR o End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> i <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 1 ! <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other � ���}'j C C'✓C7�-ur 2 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> jj7 A'' [HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q o PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q o PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 /> o 10 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § L__._ - — _f- — _ <br /> Comments ,Q f 'FC - - <br /> U -- <br /> Inspection Form Included: <br /> Comments Included: QI — ' ' <br /> --- —-- <br /> usiness Rep's Signature Phone Number Ins o nature Phone Number <br /> - 62081- -- <br /> INSTRUCTIONS ON BACK SCorrec � n+ E XA',M P E 1112F31 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />