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Waste Tire Su ly & Inspection Report FInspection Report Number <br /> 8"= State California Survey Form - Page 1 I 1 - 1127601 <br /> CIWMBB 181(New <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 /> O � <br /> Site Suffix: `r✓? 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ,/1 If Referral,choose referral type(Fill one) <br /> Identifier: Y� S��IC �)� �C>�! t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - - - ty <br /> Business or Facility Name ----- <br /> Inspected By Inspector <br /> �� �-- R0 _ <br /> Physical Address S� I 1 1 IT/1 f ` <br /> (� �j� _ Inspection Date <br /> L o,' ' ' `� " ` � Time In v Time Out `J <br /> Business Rep Title ! AM `-- ® AM <br /> ^ �G ! O 11 Q PM J Q PM <br /> I t Y 5 l�ea c - - - - - <br /> � -- - Operational Status',The Type T Business Role j Storage Type <br /> Tire Count (Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 4W Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use ® 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 ® Other t-10O 3*1 h T rr ' Sel-- - <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 /> _. -- -- ...... -- ------ <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 <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m m m <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 f CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 . 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 Other: § <br /> Comments <br /> I <br /> Inspection Form Included: 0 <br /> Comments Included: ® -A *Insper's <br /> --siness Reps Signature Phone Number S' ature Phone Number <br /> X t E���T2 3 62081 <br /> INSTRUCTIONS ON BACK Correct. Incorrect: � I � �t�� p �. � � � � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />