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■ Waste Tire ju, . ,.y & Inspection Repirt ispection Report NumberState ■ <br /> -rpt <br /> CIWMB <br /> f 81(New <br /> Survey <br /> Form Page 1 I 1 - 1140836 <br /> CIWMB 181(New nage) J merry g <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR-BLACK IN_K_PEN <br /> Business Profile Inspection Details <br /> TPID- � � � o � © Ins ection Type (Fill one) <br /> Site Suffix: 5 `;4J p- - j ® Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q� � ;u' �� �����;�/ O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical Address <br /> CA q-500 Inspection Date j 1 ut <br /> /' <br /> 1c mac_- ll t'1 h' Time In t Time Out 1 <br /> Business Rep Title Q AM <br /> Q AM <br /> A PM / '3 AD PM <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 /> O Active Q Passenger ® Generator O Outdoor <br /> O ® Closed O Altered V14 <br /> GPS Latitude i <br /> Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude _ - 0 Planned • OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader 0-Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station O Hauler O 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 j <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q 1 0 Other: § <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: 4ns <br /> - t - ti-ll`1' ''�5 <br /> P� 9 Phone Number <br /> - - - Bus Re s I gni <br /> Phone Number s S' nature <br /> - - -- -- <br /> INSTRUCTIONS ON BACK Correct: Incorrect 62081 <br /> • y� / L E l2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />