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eS Waste Tire Sfpy & Inspection Repo Inspection Report Number <br /> It <br /> StateofCalifornia Survey Form Page 1 I 1 - 1141215 <br /> CIWMB 181(New nage) Y �y <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> --- ------------- <br /> TPI <br /> - 1 5 ` 6 5 0 8 _ C) Inspection Type (Fill one) <br /> Site ffi <br /> Site Sux- II 6 o Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: '�aq �� (J �� �, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physics► Address <br /> t\� `z,,' ` � Inspection Date / j / <j <br /> Time In Time Out <br /> Business Rep Title //''�� O AM O AM <br /> L <br /> ' 0 V 0 PM � �� ® PM <br /> �er�nan �. � - �f,Jr'1e� - - - -- - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t ® Active ® Passenger ® Generator (D Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 /> ® 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 /> - ---- - - - <br /> HAUL.ING AND MANIFEST REQUIREMENTS �..�. <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> -- --- Notice Of Vlotatio Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - NoTViolations <br /> Other: § <br /> Comments <br /> -- <br /> G <br /> Inspection Form Included: Q <br /> Comments Included: <br /> B siness Rep's Signature one Number Ins ec or' i ature Phone Number <br /> INSTRUCTIONS ON BACK Correct: iiic rr'ect �/; } �l1Wi P 62081 <br /> White Copy:C!N/MB Yellow Copy:Operator Pink Copy:LEA <br />