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Waste Tire SuAyAIns ection Re OrtInspection Report Numberp p <br /> w CIWMB 81California <br /> (Now 04104) SurveyForm e 1 Il - 1088463 <br /> California Integrated Waste Management Board - Page <br /> Part A- Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I I I OA1 5 I 1 3 I t O ILI Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n �(�(} ;,,{t f\ U u(1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facil'ty Name 'l Inspected By Inspector <br /> C u <br /> Physical Address - Q <br /> Street �� <br /> Inspection Date <br /> ( ___�L-) C - `�5 <br /> CityState ZIP Code Time In Time Out <br /> Business Rep It ' Title : I ,\ O AM 1 0 AM <br /> GC <br /> t Q PM J 0 PM <br /> � co , R1u - <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 /> o� `0 Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude j � ��O Q Closed Q Altered Q Q <br /> _fL Hauler Indoor <br /> A7- <br /> 7 T_ O Q Inactive `Q Truck <br /> Longitude - Q Planned 0 OTR Q 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 Q Car Dealer Q Collection Q Crumb Rubber ) <br /> Q Service Station Q Hauler Q Agriculture Q Shredder fa Other 'v•,' {(I me k4 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> '1/ A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> 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 /> !V! <br /> Inspection Form Included: Q l <br /> Comments Included: 0 - . <br /> Business Rep's Signature Phone Number Inspectbr's Signature Plfone Number <br /> 62081 - <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: XA�, V 'E i A M ':, L i 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA V <br />