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Waste Tire Suay & Inspection Repor Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I1 - 1141315 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Anspection Details <br /> �. . 3 �6�, �. a... . . . N.::.. .. <br /> TPID- LO <br /> Inspection Type (Fill one) <br /> Site Suffix. ( t 3 } 151 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �i^ If Referral,choose referral type(Fill one) <br /> Identifier: `.� ,'1 �,�� �o�Yl 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> i <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> 1 <br /> N / Ir 1 <br /> Physd Address _�_ <br /> `� - 10 � � A1 � t <br /> -e` <br /> Street <br /> Inspection Date <br /> I r sem 1tm rfA <br /> State Zip diode Time In Time Out <br /> Business Rep Title _._ ... _....._ . <br /> 1...._. � O AM 11 1 I Q AM <br /> O PM <br /> 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) J�, <br /> Q 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> a <br /> Q Closed 0 Altered <br /> GPS Latitude i j 0 Hauler 0 indoor <br /> I.. i-•�.— — 0 Inactive 0 Truck <br /> i.. 1 D <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 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 /> 0 0 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 EX7) <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 1 <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 'Other: § <br /> Comments <br /> See ��1111 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number- <br /> 62081 <br /> umber62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X j X A, ,i►14 :' l_ [: 1 2 3 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />