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Waste Tire Sey & Inspection Rep( _ _ Inspection Report Number <br /> -fIa State of Califomia . 1 0 0 0A <br /> CIWMB191(New ) Survey Form - Page 1 1 2 0 1 9 <br /> CalifomiaIntegrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Surve _ <br /> Business Profile Inspection Details ! <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine ® Re-inspection Q Referral Q Observation <br /> LocalC(7nn <br /> If Referral,choose referral type(Fill one) <br /> Identifier: i7D Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ti Inspected By Inspector <br /> Physical Address <br /> Inspection Date b -7 <br /> Time In Time Out / <br /> Business Rep Title Q AM Q AM <br /> Q PM Q PM <br /> Cris — Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active ® Passenger ®Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude – Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V /L v EUttl. 4 Notice Of Violation ( , <br /> Q 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 Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 0 g M15 <br /> ® Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB II II II II <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required forNOVorEXT} <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!CIWMB Enforcern <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 GeneratorsQ Compliance, <br /> O O Other: § <br /> Comments f�Glh� n <br /> /Z712"70-7 <br /> _t 4 q kq. rwir, ,4 i6 4- 1 S iM i 5S+�raI aad qy_x 4,- Plea Se- 9,6il*,w'b0l a <br /> was -f�lj•o5 ��.1cj <br /> Inspection Form Included: QI <br /> Comments Included: Q tor's Si nature Phone Number <br /> Business Rep's Signature Phone Number g _ <br /> INSTRUCTIONS ON BACK Correct ' A Incorrect: ( E X a M!P LIE 1 213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />