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Waste Tire Su- ,ey & Inspection Repoll, Inspection Report Number ■ <br /> State B California Survey�p Form - Page 1 I 1 1140676 <br /> CIWMB 181(New nage) J ltiey (� <br /> California Integrated Waste Management Board "�' <br /> PartA-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection� � .� LI - � � Inspection Type (Fill one) <br /> Site Suffix: 6 ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5�S(, v� ��� (/)� W NL 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ' Inspected By Inspector <br /> Physical Address <br /> lC%�l ��t�Sr✓mlk At- <br /> Inspection Date <br /> I <br /> O / ? <br /> 1 l CLPt CC� `�' ' ��33� Time In Time Out <br /> Business Rep Title 0 AM (�( Q 0 AM <br /> 1 5 0 PM l I U O PM <br /> — – -- --- , Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> ` (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 16 <br /> f ®Active Passenger ®Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A i HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Site- MifiI(5-- - <br /> Inspection Form Included: <br /> Comments Included: <br /> i Business Rep's Signature Phone Number Inspected i a re Phone Number <br /> INSTRUCTIONS ON BACK [Corred�e Incorrect: X E 7C ,A PAE` t z 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />