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Waste Tire Sul. , y & Inspection Report ispection Report Number ■ <br /> CIWMe 81California <br /> CIWMB <br /> Survey Form - Page 1 I 1 - 1140877 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (:. ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S` -'Zicl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> `- r p �_^ Inspected By Inspector <br /> l� : Y o'-7 �V Cly / %I'C� 7 _ <br /> Physical Address < <br /> � y��cInspection Date <br /> s` <br /> Time In Time Out <br /> Business Rep Title // / ® AM 1 O AM <br /> L) 0 PM 2. '7 PM <br /> ------ — --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 0 It <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> . � � S" S <br /> Active Q Passenger ®Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned ! OTR <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government ® Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 j PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB ru <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O - - - - - - <br /> 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 /> in Compliance - No Violations <br /> Q Q Other: § -- -- --- <br /> Comments <br /> Inspection Form Included: ® /� <br /> Comments Included: -- -- - - ----- ---- ---- <br /> Business Rep's Signature Phone Number pector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr t � ncorrect: � e X A h4 P lr �' 1" 2131 <br /> ■ White Copy: IW Yellow Copy:Operator Pink Copy:LEA ■ <br />