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® Waste Tire ESvey & Inspection Repce Inspection Report Number <br /> .a <br /> State of California - <br /> CIWMB 181( eaSurvey Form - Page 1 I1 - 1143623 <br /> California Integrated WasttM <br /> Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Inspection Details <br /> D i Inspection Type (Fill one) <br /> Site Suffix: 1 ( ;, - <br /> (S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _ _. QCHP QCIWMB QComplaint QEducational Visit <br /> Q Other <br /> Business or Facility Name - <br /> -. Inspected By Inspector <br /> Physical Address 7 <br /> ............_....-.-�1 t�_..............._4.c._:...._._..:1....::YY.--:..._..... -_..........._.._............................................._.......`.............__._..._................:_......_.._._.._._.......... ..,..... ....„y,...�._.,..„,,.Street / <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title _ ` 0 AM 0 AM <br /> 0 PM <br /> PM <br /> Operational Status Tire Type Business Role Storage Type <br /> ;(Fill one only) (Fill all that a <br /> pply)�', (Fill all that <br /> apply) (Fillal that <br /> a <br /> p <br /> ply)1re CounVlQ Active Q Passenger Q Generator Q Outdoor <br /> GPSLatitude C �Closed � AterecQHauler Q Indoor <br /> Q Inactive Q I,u kO I Q End-Use C ContainerLongitude F-1 <br /> "',.-. Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station (S 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 AND MANIFEST REQUIREMENTS <br /> - - -- ----- 'Q Notice Of Violation Q Extension <br /> Q Q 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 RequirementsD ate M___ / Ell 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB FF1. <br /> Q Q i 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 <br /> Q Q Other: § Q In Compliance - No Violations <br /> Comments - <br /> __ <br /> _.__._.. -__.. <br /> .0-tionForm 9ncluded: Q - -- <br /> Comments Included: Q' <br /> Business Rep's Signature Phone Nurrsber hlspk7,ctcr's Sit3n_tWre Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ° ...___\/ 62081 <br /> Fe �, g <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />