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�!�!te Tire Sy & Inspection Repo Inspection Report Number ■ <br /> �"•� i-� ifornia <br /> CIWMB181`fornia 104). Survey Form - Page 1 [ri - 110847 1-- . <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill o <br /> ne <br /> ) <br /> Site Suffix 1@ Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t �� -� ���} i Q CHP Q CIWMB Q Complaint Q Educational Visit Q other <br /> Business or Facility Name Inspected By Inspector <br /> I C-)s uC e � _ <br /> Physical Address t ' r J ! <br /> Y � � [nt� �fCttitt<t� <br /> Street ++ _ Inspection Date I '� <br /> 20151 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> EE (0 PM EE . PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire CountWhole/PTE <br /> ` ) f f Q Active ® Passenger Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer, Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 1@ Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> L E),Service Station Q Hauler- —Q Agriculture Y 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 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 / <br /> _ M / Ffl' M <br /> Q Q <br /> 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 ulers.R Q Referred/CIWMB Enforcement f- <br /> Q ' Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use F ilities <br /> t -------- — ° - ------- — <br /> Q 1 Q 14 CCR§18462-.Manifest System Requirements for Tire Dealers t Wa- Tire Generators f a In Compliance - No Violations <br /> 010 Other: .§ ) ti <br /> Comments i <br /> t `, _(_JI1L <br /> 1 44 <br /> Al L K ) <br /> Inspection Form Included: 01 J, <br /> / l <br /> Comments Included: G . _ .. : , -- -- - ---I---------------- .. --- —. - <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> ,�/ 62081 <br /> INSTRUCTIONS ON BACK ' Correct: Incorrect: X V� ! X A M P :L )E X11 Z 3 <br /> �= White Copy:CIWMB Yellow Copy;Operator Pink Copy:LEA ■ <br />