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;, <br /> Waste Tire S ,/ �c Or�SpeCti®rt Rep►® _ Lnspection Report Number <br /> State of California p� <br /> ��r CgWMB 181 teManag) Survey <br /> Form - Page <br /> 1 T 1_ 1141252 <br /> California Integrated Waste Management Board V �/G' mJ r aUJ j <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- i 01-9-AI _ l M: <br /> Inspection Type (Fill one) <br /> Site Suffix: <br /> j Routine 0 Re-inspection Q Referral 0 Observation <br /> Local r-^ If Referral,choose referral type(Fill one) <br /> Identifier: !) .� <br /> ���L r 41 t ( CHP Q CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name -- <br /> r, Inspected By Inspector <br /> _ � r <br /> Physical Address � - � Il_ LP I � <br /> l � vc <br /> _....._........-__.............� Inspection Date � <br /> l V <br /> 7 ...,...„0 .............. <br /> i <br /> :tat<aZtp Code j Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> . Q <br /> .! ( J Q PM ) O PM <br /> Operational Status Tire°fype Business Role [�''Storage Type <br /> -sr CC3unt�Whoie/PTE} (Fill one only) (Fill all that app,ly)i (Fill all that apply) (Fill all that apply)' <br /> ., :... �.:, 0 Active ( Passengerr 0 Generator 0 Out 10 r <br /> �0 0 Closed D Altered <br /> GPS Latitude <br /> 0 Hauler 0 Indoor <br /> - Inactive 0 Truck, <br /> _... _. ._ ...__ ... <br /> _7 p (- <br /> Longitude - 0 End-Use 0 ;ontalne <br /> �.w <br /> 0 Planned 0 0-1—R <br /> Business Type (rill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 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 /> LOU Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCE11 MENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS �N µ.w.1 <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 m / m / m <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 (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 I 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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ` <br /> Inspection Form Included`. 0 - <br /> Comments Included; 0 <br /> Business Rep's, Signature Phone,Number lr�speeQot'sicnaf Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ; A = i' t 62081 <br /> ® White Copy:'CIW Yellow Copy:Operator Pink Copy:LEA <br />