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a <br /> Waste Tire Sr*y & Inspection Rep _ .t Inspection Report Number - <br /> is CIWMB;California <br /> Survey Form - Page 1 11 - 1141213 <br /> California Integrated Waste Management Board Y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � r � - � � I Inspection Type (Fill one) <br /> Site Suffix: ✓° ) Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ► 1 � ^bv ' v Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> PhysicalNd � <br /> Inspection Date � Q <br /> rx-e,�c�� f✓L�Ill.P CCA,_e— L5o8 1 <br /> Time In Time Out <br /> Business Rep Title ®AM �> AM <br /> S-1r4K o r <br /> -- - ---- - - - Operational Status Tire Type Business Role Storage Type <br /> 8 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> � f ®Active Q Passenger ® Generator ®Outdoor <br /> - - - O Q Closed Q Altered <br /> GPS Latitude • Hauler ® Indoor <br /> O Q Inactive 40 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT:STAT, S <br /> V A' . HAULING AND MANIFESTAEQUIItEMENTS 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 pe4T,", <br /> 14 CCR 18459.1 -Tire Program ID Number from CIWMB ° <br /> Q Q ; m Q Q 14 CCR§ 18459.2.1 Submittal of Comprehensive Trip Logs within 90 days {Required forNOyorEX7) <br /> i - ` <br /> �r <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years ti <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities i <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators o` � I0 � <br /> 1 <br /> Q Q i Other: <br /> Comments <br /> Gm --� -- <br /> Inspection Form Included: QI (�( i/1 �5a/�-��� <br /> Comments Included: � - - - -- - — - 5/� Z rte_ <br /> Business Rep's Signature Phone Number I s c is,s'& ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK � Ttte '� � � A- 1 P L � 3 <br /> — <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />