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■ Waste Tire Survey 811. Inspection Report Inspection Report NumberState ■ <br /> .,� <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1143588 <br /> CIWMB 161(New nage g <br /> California Integrated Waste Management Board `�' <br /> P-4 A-Survey_ BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> ,0_ � 5 (� � © Inspection Type (Fill one) 1 <br /> Site Suffix: I Q' Routine Q Re-inspection Q Referral Q Observation <br /> Local e— If Referral,choose referral type(Fill one) <br /> Identifier: S Gl n J 0��� C0 ,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> o� <br /> Physical Address I t7e,� CStrb- <br /> a5 S <br /> C� L� Inspection Date <br /> , <br /> SG�Ip <br /> Time In Time Out <br /> Business Rep TitleS I e ® AM 5 � AM <br /> LA S �. C 4 fi�� B T 1 L I • 15 O PM ` J Q PM <br /> �` V Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /ry (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> Latitude <br /> ---_---- — — -- --O IS Closed Q Altered MA <br /> GPS 1 Q Hauler Q indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned (a OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> lew 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 Q Hauler Q Agriculture Q Shredder t'* Other Uw4s o c,r <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I AHAULING 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 Requirements Date m / 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 Q Other: § <br /> Comments iwf T u J <br /> ection Form Included: 01 <br /> Comments Included: ® <br /> B�"usiness Reure Phone Number lnspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect i. i ! 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />