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Waste Tire Su. .ey & Inspection Repor Inspection Report Number ■ <br /> •t11 State of California <br /> �r CIWMB 181(NewSurvey Form - Page 1 I 1 - 1143729 <br /> California Integrated Waste Management Board <br /> PartA- Survey___ _. _ .-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O I Inspection Type (Fill one) <br /> Site Suffix: ` $ 1 ® Routine Q Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: an O Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> CI. U_ n 4�1 <br /> Business or Facility.Name Inspected By Inspector <br /> �•� ��� e �i t`t�,t1�pc�r-ta�cin - � 0 � <br /> Physical Address -1 1) 4 <br /> C� g53ti� Inspection Date <br /> Time In Time Out <br /> Busir�e1ss�teR Title Q AM Q AM <br /> tidh O <br /> M O PM <br /> G ly c� 01,1 Ae, - ----- - - - -- - - - - - <br /> - - -- - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (� I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 'd �g •Active Passenger ® Generator ® Outdoor <br /> O Q Closed 0Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O O Inactive 40 Truck <br /> Longitude - Planned OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer •Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O 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 N FORCEMENT STATUS ll <br /> V A ;HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> I <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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 i 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> I <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 I' 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> OO 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> O O <br /> Other: § <br /> Comments <br /> Inspection Form Included: 5 83 L .. , <br /> Comments Included: �I -- J- �� -� C�J�dV� ���J�wOrJ1� <br /> Business Rep°s Signature PIYOne Number Inspe t r°s Signature Phone Number <br /> - - --. <br /> — --- <br /> INSTRUCTIONS ON BACK Correct: incorrect: ^' V;1 , p 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />