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T <br /> f <br /> 08126040878 <br /> "" Waste Tire Survey & Inspection Report Inspection Report Number,State V �. <br /> i CFWMB181(KwCallfornlSurvey Form - Page 1 I1. - 1103817 <br /> CIWMB 161 pre-nag Y ('� <br /> Cslitomle IntagrateC Mate Mane60rnsnt aoarA `�J' <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / 6-- L ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ff Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> . _ _ _ _ress [5& <br /> Street <br /> 7v Inspection Date <br /> City / State t� Time In J Time Out 1/ <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type. <br /> y I (Fill one only) (Fill all that apply) (Fill all that apply), (Fill all that apply) <br /> Tire COunt-(Whole/PTE)' I . <br /> r. r • SPActive Q Passenger &Generator Outdoor <br /> – ---- -- - - - --i0 Q Closed Q Altered <br /> GPS Latitudei Q Hauler Q Indoor <br /> — Q Inactive O Truck <br /> Longitude - i + T -30 Q planned Q OTR Q End-Use Q Container <br /> l' <br /> Business Type (Fill all that apply) . <br /> Q New Tire Dealer Q Auto Repair *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 ND MANIFEST REQUIREMENTS <br /> Q once Of Violation Q Extension <br /> Q Q <br /> 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 <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 HaulersQ Referred/CIW MB Enforcement <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 10 1 Q Other. <br /> Comments <br /> WI-If it //' <br /> WA-we- aAqd4,n;.l <br /> 07, <br /> Inspection Form Included:Q 0 �/ <br /> Comments Included:Q <br /> Business Rep's Slgnature Phone Number Inspectoes Signature- Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> EXAMPLE' 123 <br /> ■ White Copy.CIWMB Yellow,Copy.Operates Pink Copy.LEA ® ■ <br />