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Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> 11' CIWMB 81'fornia <br /> (New 04/04) SurveForm - Pa e 1 I1 - 1143612 <br /> y <br /> California Integrated Waste Management Board J <br /> _ BLUE OR BLACK INK PEN <br /> Part A-_Survey <br /> Business Profile- Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 2 a Q Routine ® Re inspection Q Referral Q Observation <br /> Local �, �� If Referral,choose referral type(Fill one) <br /> Identifier: L� �� `-v"r " �f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (t Inspected By Inspector <br /> 51)CL lug r ,mss ; A <br /> Physical Address <br /> Inspection Date it G 1 O <br /> CA 175, Time In Time Out <br /> Business Rep Title ` 0 AM 0 AM <br /> 6 0_ 0 PM O QPM <br /> ---- ---- -- Operational Status I 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 /> ®Active ® Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive � Q Truck <br /> Longitude - Q Planned 1 Q OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> I A HAULING AND MANIFEST51 -Waste Tire REQUIREMENTS <br /> Registration RdTransport of Tires <br /> MEN S Q Notice Of Violation Q Extension <br /> Q PRC§ <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 <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 Q 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 ® In Compliance - No Violations <br /> Q 1 Q Other: § — <br /> Comments <br /> Q <br /> Form Included: <br /> Ins <br /> Inspection �(P� <br /> ^ - -0.� - 22 <br /> P i �f ( J� C —S <br /> Comments Included: - <br /> d t y� f6 T <br /> Business Rep's Signature Phone Num 'r I �e ors I natur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect X �� � E P? 1 !, 2131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE ® ■ <br />