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iz <br /> Waste Tire Sy & Inspection Repor. Inspection Report Number ■ <br /> lli7 State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1140905 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection j / Inspection Type (Fill one) <br /> Site Suffix: 7 a ® 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 orFacilityFacility Name Inspected By Inspector <br /> Old 6wr`- a f <br /> Physical Address 3 <br /> f t�3 o <br /> t-- Inspection Date ^t a 0 <br /> /ru.cl <br /> Time In Time Out <br /> Business Rep Ti <br /> en / <br /> ' N1 f 0? 3 ® PM V / l � ® PM <br /> J - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I® Active Q Passenger I ® Generator Q Outdoor <br /> Latitude O Q Closed Q Altered i <br /> GPS -- - - - Q Hauler Q indoor - <br /> O Q Inactive 16 Truck Longitude - Q Planned Q OTR Q End Use j Q 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 �J <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> U 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 /> 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 <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years i <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/£IWMl3 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 <br /> In Cdtnptlattce '•'l�lo Voiatort&, T <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: 0v C� <br /> Comments Included: -- -- -- <br /> Busi a Rep's Signature - Phone Number Inspector's Signature Phone Number <br /> t 62081 <br /> INSTRUCTIONS ON B Kol`rt� li�►arr ��� (E;9t I A, � 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LE <br />