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Waste Tire Amy & Inspection Rep" Inspection Report Number ■ <br /> r" State of California Il - 1143634 <br /> CIWM6181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey- BLUE OR BLACK INK PEN <br /> Business Profile j Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` —� l l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identifier: { - (�� ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> Physical Ad ress <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM , //��,, O AM <br /> ' O PM V ® PM <br /> --- -. - -- -- <br /> ci rF'r <br /> ------ -- -- -- -- - ---- Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t 0 Active 40 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> O O Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V T q HAULING AND MANIFEST REQUIREMENTS <br /> O O O Notice Of Violation 0 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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB 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 1 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 0 Other: § <br /> Comments1� -7A—, <br /> V <br /> Inspection Form Included: <br /> p OI <br /> l�� igg_ <br /> 967 <br /> Comments Comments Included: 0 - ��" "-- -- <br /> B ess Rep's Signature Phone Number rto s S' nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: V' f: X A P'j l 23 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE ® ■ <br />