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Waste Tire SL. -%y & Inspection Repor) -Inspection Report Number <br /> State of California <br /> CIWMB1811(New04104) Survey Form - Page 1 I 1 - 1127598 <br /> California Integrated Waste Management Board -. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPID- ; �j {y I I Inspection Type (Fill one) <br /> Site <br /> Site Suffix t `b <br /> 1 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��? r1 �QC1� �(1 n C( � j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> T1 I <br /> ;\ ( utt('' U tLUCt!_1� 1►1t,�i��C�il4l(�. i . �. ....._ <br /> Physical Address <br /> Siree? <br /> Inspection Date <br /> City � State ZtF Code Time In Time Out <br /> Q AM <br /> Business Rep Title Q AM i <br /> i � � � O PM i i�. O PM <br /> nuc r. P, ------ 1ac� <br /> Operational Status Tire Type Business Role Storage Type <br /> t <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude � . � j � j <br /> 0 0 Closed O Altered <br /> GPS I I I 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 0 Referred/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 0 In Compliance - No Violations <br /> 0 0 Other: § - j <br /> Comments "C I � k d I, r -� Ulf, <br /> it` � � t1 � �. t � .i <br /> i <br /> ` 1 f <br /> ib <br /> Inspection Form Included: b <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X 1 A M1 P L P i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />