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f <br /> Waste Tire Su*e & Ins / ins Re <br /> ■ y Inspection Repor _ p ection Report Number <br /> State of California � --- <br /> CIWMB <br /> grated 1(New Mana a) Survey Form - Page 1 � ' I 1 - 1088200 <br /> California Integrated Waste Management Board <br /> Part Ac <br /> - Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /c--- Inspection Type (Fill one) <br /> Site Suffix: -- _ - <br /> �.. __._ ��_�__� �� <br /> * Routine QRe-inspection QReferral <br /> Q Observation <br /> Local <br /> ' If Referral,choose referral type(Fill one) <br /> Identifier: I J <br /> Q CHP Q CIWMB Q Complaint Q Educational visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> LIM— <br /> ( h/ P//4 r'i <br /> Street <br /> - Inspection Date <br /> Cit'' State ZIP Code Time In AM Time Out <br /> Business Rep Title � 0 AM <br /> O PM <br /> r �.. � F 9 ' O PM <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 /> 0 <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - . End-Use Container <br /> 999 { ! Q Planned Q OTR Q Q <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 /> I Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> /s / <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> -- 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 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 /> - --- -- .. <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 1 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 <br /> § Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments _) / _ - - - <br /> c,t��.:� ,� �._�� %. .lam . ✓ <br /> Inspection Form Included: Q <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 4 V E=:.�jA �'i , L 1� j 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />