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= aWaste Tire S & Inspection Re <br /> oOd'oection Report Number <br /> �IMB1W81(New 04104) <br /> Survey Form - Pa e 1 I 1 - 1143731 <br /> California Integrated Waste Management Board J <br /> Part A- Surv> - - _ BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Q � � - O � Inspection Type (Fill one) <br /> Site Suffix: o ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 aI) JOCI JIkN!n Cc7u n�j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business of6k� <br /> icility Name `1 ) Inspected By Inspector <br /> co I� d ► of(NI, " SPhysical Address 3 I ' <br /> LoC O CA ��8-1h Inspection Date O I n <br /> \1„' V Time In Time Out <br /> Business Rep Title • AM Q AM <br /> QPM p0. ` � ® PM <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 /> O Active Q Passenger Generator ® Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler O Indoor <br /> O O Inactive ® Truck <br /> Longitude - Q Planned 0 OTR O End-Use Q Container <br /> Business Type (Fill ail that apply) <br /> O New Tire Dealer Q Auto Repair 0-Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Other �11LfG�ent��K,G� �� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O O Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 ® In Compliance - No Violations <br /> O O Other: § <br /> Comments �- <br /> wk�`�k�c` . on <br /> Is) 0V tt 0 ' �,rs s ca ce,v..5 0+ c on af'n. — <br /> ,Inspection Form Included: O <br /> og L 4 4 4 71 9 6OWPhone <br /> - <br /> (10Comments Included: Business Re''s Signature Phone NumberInspe is Signature Number <br /> INSTRUCTIONS ON BACK Correct. --Incorrect: 6% M1 E X A P L E1 1112T31 62081 <br /> `-/ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />