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r Waste Tire Su, y & Inspection Report ispection Report Number <br /> =a, <br /> Slate of California <br /> CIWMB1811st(New Manag) Survey Form - Page 1 I 1 - 1140860 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• I - j Inspection Type (Fill one) <br /> Site Suffix: f l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: } Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name fK( l <br /> Inspected By Inspector <br /> PftwAn <br /> ical Address <br /> ox ve <br /> �t Inspection Date <br /> Tilne In Time Out <br /> Business Rep Title �y ® AM ® AM <br /> 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 Q Passenger ® Generator ® Outdoor <br /> _G,RS Latitude Q Closed Q Altered <br /> Q-Hauler- <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 0 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 <br /> 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ! Date / <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB m m m <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 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 ® In Compliance - No Violations <br /> Q 0 Other: § <br /> Comments � <br /> fznA'�1 c.j T G2�rx+�s. 42Lc_,1./ <-`-- <br /> 1Ct _ dw/cod <br /> T <br /> Inspection Form Included: Q x �� <br /> Comments Included: ® r —[ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number. <br /> X I I E I I 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � F= ;� ,� � >� � � <br /> White Copy:CIWMB Yellow Copy:,Operator Pink Copy: <br />