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., Waste Tire SL :y & Inspection Report Inspection Report Number <br /> State of California <br /> or CIWMB181 <br /> Waste <br /> eManag ) Survey Form - Page 1 I 1 - 1141219 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix 11 151-19 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local `- If Referral,choose referral type(Fill one) <br /> Identifier. 4 1 iC1 V �(.(iy Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Physical Address <br /> .. �� 5_ r"� c. _<__ - <br /> 5?reet ................._...._.-. <br /> Inspection Date <br /> t C L cS 3G�1 I 017 <br /> _..� <br /> Slate ZIP Code Time InTime Out <br /> Business Rep Title j 0 AM 1 r / Q AM <br /> 1 <br /> 0 PM <br /> t 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck. <br /> Longitude - Q Planned Q OTR Q End-Use 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> - - - - --- 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 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 0 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> CommentsRL_ -�� �� 1 )tel f7c�7 t rx-21-j C C. : i d/1 CCC- ri 1 Jc <br /> -�t- — ab �� � 't-a 1 ► 1 J Ct - I - <br /> �J 4' { 1 r <br /> } <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 52081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X V U X+A M (_ 1 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />