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== Waste Tire Suf^ & Inspection Report%spection Report Number <br /> >, <br /> State of California <br /> CIWIVIB 1st(New <br /> Manag ) Survey Form - Page 1 I I - 1140868 <br /> California Integrated Waste Management Board <br /> Part A- Survey - _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> � Z_ - vl <br /> Site Suffix: 8 r _ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - -— <br /> /� ` Inspected By Inspector <br /> Physical 'A dresslab (IC / ��1,L' L L <br /> Inspection Date /� / r <br /> I Q 1 <br /> Time In Time Out <br /> Business Rep Title <br /> a Sy U ®AM y ® AM <br /> QPM , QPM <br /> - � --- 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 /> ' ® Active Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ®Truck <br /> Longitude - Q Planned 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 STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - — -- - 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 Date m / LL] / m <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 Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q ®Other: § <br /> Comments <br /> 1 'C U1.UEt'yj ���Q�..)`�a/u �°t Cr�.Cat� <br /> Inspection Form Included: Q _/ <br /> Comments Included: III (201 L16 2 <br /> Busln Ws Si lure Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E XjW01 64f 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy <br />