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Wa to Tire Su & Inspection Reporo Inspection Report Number <br /> State of California Y - - - ■ <br /> p� CIWMB 181(NewSurvey Form - Page 1 I 1 - 1088071 <br /> California Integrated Waste Management Board g _ <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details Y <br /> TPID- C ��� j �L <br /> -- Inspection Type (Fill one) - <br /> Site Suffix: _ @ U' I 4 I � � / ! Cl—l. t _ I It) Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: / <br /> C C_•t �``-J I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> (Physical Address- <br /> Street <br /> Inspection Date / / <br /> StateZir G`ode Tlme In Time Out _ <br /> Business Rep -- <br /> TitleO AM O AM 0 PM <br /> j : F�j 7 <br /> 0 PM <br /> Operational Status Tire Type k. Business Role I Storage Type <br /> (Fill one only) (Fill all that (Fill all that apply) (Fill all that apply):; <br /> Q Active Q Passe 'h'` ® Generator Q Outdoor <br /> GPS Latitude . Q Closed Q Altered(- <br /> Q Hauler Q Indoor <br /> 1 - — - D Q Inactive Q Truck <br /> Longitude - d Q Planned Q OTR Q End-Use Q Container <br /> —-- .II 111 <br /> Business"type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> — — _ <br /> V A j HAULING AND MANIFEST REQUIREMENTS -- - - <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q 1 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> p <br /> Q 'I Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / / <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> m m []] <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 <br /> Q I Q I Other: § <br /> ® In Compliance - No Violations <br /> Comments <br /> Inspection Form Included: Q —— — - -- <br /> � <br /> Comments Included. 01 <br /> PhoneNumber <br /> Business Rep's Signature Phone Number Inspectors Signo�ture <br /> _ ,... <br /> ® INSTRUCTIONS ON BACK Correct: XIncorrect: , 62081 <br /> P11 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:L17A( ■ <br /> � u <br />