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Waste Tire Su, ay & Inspection Report Inspection Report Number ■ <br /> State CIWMB California 181(New I 1 - 1140845 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey__ __- _ - BLUE OR BLACK INK PEN <br /> Business Profile lInspection Details <br /> --- - - <br /> � TPID- Inspection 3 � � _ � � Inspection Type (Fill one) <br /> Site Suffix: / 10 3 .J Q Routine s Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: „[mac., Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `'"•— J <br /> Inspected By Inspector <br /> Physical Address <br /> GA45-2-o(" Inspection Date 1 <br /> Time In Time Out <br /> Business Rep Title / i AM O AM <br /> 0 P / ® PM <br /> - - =J---- --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f J ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed ®Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck � <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader IS 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 /> ---- ------ ------ <br /> V I 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 <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 I* In Compliance - No Violations <br /> Q Q Other: § I <br /> J <br /> Comments 6�:lit�'� IBA p llGLu�'s t-�S <br /> Inspection Form Included: Q 06 Z <br /> Comments Included: ®I <br /> Business Rep's Signature_ Phone Number Inspector's Signatur Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK �correct: Incorrect X X R I_ a; I jZ 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: ® ■ <br />