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" <br /> Waste Tire SAWy & Inspection Repos Inspection Report Number <br /> Stale of California <br /> a@rnia CIWMB 181(teManag) Survey Form - Page 1 �- 11.2710- 06 <br /> Calrfornia Integrated Waste Management Board _. <br /> Part A Survey p BLUE OR BLACK INK PEN <br /> I Profile Inspection Details <br />{ TPID" <br /> InspectionType (Fill on <br /> Site Suffix: QRoutine Re-inspection0Q Referral <br /> Observation I, <br /> Local � € If Referral,choose referral type(Fill one) <br /> Identifier: C, <br /> i�' ( (-) l Q CHP Q CIWMB 0 Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> EEO 1I <br /> AT've <br /> Physical Address 'S ! ��� _. <br /> r c r <br /> Inspection Date i I i �)TO, <br /> Sia; I Cnd� Time In Time Out <br /> Business Rep Title (3 AM j € Q AM <br /> /� <br /> �).– r� / (C�' O P M ti J QPM <br /> (....C.�1_�.__.t1_ ..� .. ......._..._ .._.__... ...! _. i.. >i� �. . +� ..... ........., /.__.._. _.. ...3..... <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill 911 that apply) <br /> Q Active 0 Passenger 0 Generator C) Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> (— Q Inactive 0 Truck <br /> __.._._.....___ _..___.___ O <br /> Longitude – i 0 Planned Q OTS 0 End-Use Q Container <br /> t <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder 0 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 /> ------ — Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 Ii 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m , / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB LU <br /> 0 0 (Required for NOV or EXT) <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> f N <br /> -- <br /> inspection Form Included: 0 <br /> Comments Included: 0 , <br /> Bt siness Rep's Signature Phone Number inspector's Signa.ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />