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Inspection Report Number <br /> Waste Tire Su&y & Inspection Repor ■ <br /> Stateof BCalifornia Survey Form - Page 1 1 7 - 1 019 1 6 3 <br /> CIWMB 181(New nage) Y ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- A - ` Inspection Type (Fill one) <br /> Site Suffix: , ` / ® Routine Q Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:/�p P1 O CHP Q CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Inspection Date 03 / 9 O r'`�532a Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> g'leti [.*t-i ©IOAleo_ _— 0 PM 0 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 /> *Active S Passenger ® Generator &Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O O Inactive 0 Truck <br /> Longitude - O Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> * New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> 40 Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> LL --_ rand End Use Facility ENFORCEMENT STATUS ' <br /> Part B Inspection of Waste Tire Dealer Generator Hauler <br /> HULING AND MANIFEST REQUIREMENTS <br /> '""" -- - -- ---� Q Notice Of Violation Q Extension <br /> O O 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> ---------- <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ---- -- --------------- <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers j Q Referred!CIWMB Enforcement T <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violation <br /> 4i0 1 Other: § / `-- <br /> Comments <br /> LC�Je�rt�ltr� 1�f �hoc�-c���_��2- - ��' � ,�,40- ��,.s�,�c_.t� f,►2� <br /> Inspection Form Included: O �7per, <br /> Comments Included: Q /Xf <br /> r� `3 <br /> Business Rep's Sig ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACKE"� E 2 3 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />