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as Waste Tire Su*,y & Inspection Report•Inspection Report Number <br /> State California I 1 1141016 <br /> CIWMBI3 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A. Surve_y____ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �7 Q Inspection Type (Fill one) <br /> Site Suffix: 5 -3 f 1 © j <br /> Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1- 4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — - -- - <br /> _ Inspected By Inspector <br /> 1 <br /> 1� <br /> �� ham► W <br /> Physical Address �5 ,� � - ! 0 w/ <br /> Cod <br /> Inspection Date D 1 / � / Q <br /> °J S�Z(�S <br /> Time In Time Out <br /> Business Rep Title ) ® AM / ® AM <br /> TGL 1 C� 0 P i J� d 0 P <br /> 41 Operational Status Tire Type Business RoleStorage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> T � ® Active Passenger ® Generator Q Outdoor <br /> Closed Altered Hauler Indoor+� <br /> GPs Latitude O Q Q <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> - - - - - <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 /> 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 /> V1, `HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension I <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 O 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date <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 i <br /> (Required for NOV or EX7) <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 In Compliance - No Violations <br /> 10 0 Other: § <br /> Comments nn <br /> 1-fit VLe, <br /> - i <br /> Inspection Form Included: <br /> Comments In ® JV�'1w 1`I1/Y►/1L �2o �.tn0(o$�c7tp Z <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> 4, 62081 <br /> INSTRUCTIONS ON BACK I� ��II VIII CO� ct 1 1 <br /> ■ ® ■ . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: E <br />