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Waste Tire Su&y & Inspection Reports Inspection Report Number <br /> State California Survey Form - Page 1 11 - 1127609 <br /> CIWMBB 181 thew 04104) Y <br /> California Integrated Waste Management Board _.. _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> nspection Details <br /> TPID- Q .' r Inspection Type (Fill one) <br /> Site Suffix: =01 <br /> 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier. ` q 1 �(.l tC L, I' LL ! 1 �(./ 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 — c,I <br /> Physical Address <br /> L..._r:......1.... i...m .............. .._...._.._....... <br /> ............ ...)._1_z....;... ..._r......................L Y ......................._................... <br /> .....J <br /> Street /Inspection Date <br /> —7 Lct��] <br /> / Lq <br /> �( <br /> f rJy Slate 1 �C l oI� Time In Time Out <br /> I '­ _T* <br /> � Zf, C ele <br /> Business Rep Title / <br /> C� <br /> O PM �! O PM <br /> r Operational Status Tire Type Business Role Storage Type <br /> Tire COUnt(Whole/PTE) <br /> . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> } Active Q Passenger ) Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> FF_ <br /> Q Inactive Q 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 /> Q Used Tire Dealer Q Auto Body a 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 HAULING AND MANIFEST REQUIREMENTS � <br /> -- --- <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / 7 <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 /> 6+ut l`l lr` Pl tVit)e - ] 7 1 <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> e_. 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1 j 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />