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= Waste Tire SL- ,iey & Inspection Report Inspection Report NumberState ■ <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 Il - 1143644 <br /> CIWMB 181(New nage) Y <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 159 a Q Routine Q Re-inspection 41 Referral Q Observation <br /> Local C \\ '(_Y l 06341 If Referral,choose referral type(Fill one) <br /> ` + <br /> Identifier: Q CHP Q CIWMB 40 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> ��j Inspection Date <br /> �` ��� Time In Time Out <br /> Business Rep Title "� 41 B AM �j Q AM <br /> / l7(. / Q PM ! ® PM <br /> Gt 11GL — -- - - - <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 /> D ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude – Q Planned Q OTR Q End-Use is Container <br /> Business Type (Fill all that apply) <br /> Q 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 ® Otherob� <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 Q Other: § <br /> Comments <br /> Inspection Form Included: Q q //``�� 90 c� <br /> Comments Included: -_- --Gvl "_"LS - /a [ <116 '-l' 73 -- <br /> Business Rep's Signature _Phone Number In p ctor' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect: X/ ��/! X� JUti�P + ( 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop LE <br />