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L6 Inspection Report Number <br /> Waste Tire Su :y & Inspection ReportState <br /> CIWM of California Survey <br /> um/e Form Page 1 + i 1127496 <br /> CIWMB 181(New nage) V , ,r y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE-OR-BLACK INK PEN <br /> I Business Profile <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> l I 3 L'� O 0 Routine O Re-inspection O Referral O Observation <br /> Local - � © _ ��L If Referral,choose referral type(Fill one) <br /> Identifier: (-�_(-� 11 O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name - -- -- - -- <br /> Inspected By Inspector <br /> G� i rvc �cJ <br /> Physical dress <br /> �� ���I Inspection Date <br /> � <br /> Time In 1 Time Outl <br /> Business Rep Title j0 AM 0 AM <br /> f <br /> ` QPM o2 / O ®PM <br /> - ---- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l ® Active 0 Passenger ® Generator ®Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive ® Truck <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair ®Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility LENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS————---- -- ----- O Notice Of Violation O Extension <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 /> i <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> O O Other: § <br /> Comments ; <br /> zy_1 _ - <br /> Inspection Form Included: Oj y/ j ' ( /f Q <br /> Comments Included: OJ `�- - �'✓ L % Jd __C �' -- - 76 O !�- <br /> - Business Rep's S'- nature Phone Number - In t s ignature Phone Number <br /> INSTRUCTIONS ON BACK 1 =} 'h� p 62081 <br /> White Copy:CIW Yellow Copy:Operator Pink Copy:LEA <br />