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Waste Tire Sur% & Inspection Report spection Report Number <br /> State CIWMB 181(New Il - 1140590 <br /> grated Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f (1 Inspection Type (Fill one) <br /> Site Suffix: f 5- ,3 6 Gf � � 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: QIVICHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> � � N Inspected By Inspector <br /> Pre 5!� (��-L+?�l k./�!-c 7 A i�l�62�VLk���✓.�M 1 1 — ` _ <br /> Physical Add ess <br /> J Inspection Date d o / L 7 <br /> j� <br /> Time In Time Out <br /> Business Rep Title <br /> / � � 0 A 0 A <br /> �J ✓ Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> T" 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 J <br /> V A 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 /> 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 <br /> (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 /> l <br /> Inspection Form Included: 0 <br /> Comments Included- 0 <br /> Bu ness e s ignature hone Number Soectoes.Signat a Phone Number <br /> - T r— <br /> INSTRUCTIONS ON BACK Correct: 62081 <br /> Incorrect: X A � (- 11 2� <br /> White Copy:CIWMB Yellow Copy Operator Pink opy:L <br />