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Waste Tire ey & Inspection Rep( Inspection Report Number <br /> State of California 11 - 1127744 <br /> �r <br /> CIWMB Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i Inspection Type (Fill one) <br /> Site Suffix: ` 3 Q ` i® Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local ! If Referral,choose referral type(Fill one) <br /> Identifier: 'D C\Y'\ \ ` C �,� �v� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical ddress l I l J l S© ,►W7I �C� <br /> Inspection Date I J Q Q C� <br /> Time In Time Out <br /> Business Rep Title1 ®AM 2 O AM ' <br /> � \, I Q L � O PM ` � v 6 0 PM <br /> `�`� � �v" w ` <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 ® Passenger ® Generator ®Outdoor <br /> O 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 OTR <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 ® Other ��� -tri-ki 'Ape' M P&_ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FEN-FOR-CEM-ENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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: § L �o <br /> Comments 1IreC� CT71 :A, <br /> ` r f <br /> A10 V >-o --i is c-r Lz_s c) ee-m <br /> Inspection Form Included: Q Iry _ <br /> Comments Included: Qy(/ v` vP 1� 7 f! - <br /> Business Re 's Signature Phone Number _I p t� s nature Phone Number <br /> 01 <br /> INSTRUCTIONS ON BACK Correct: Incorrect. I X I 1 ! 2 131 <br /> 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE �� ■ <br />