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■ csii Waste Tire Su; :y & Inspection Report tspection Report Number <br /> State CIWMB California I 1 - 114 0 9 81 <br /> grated fst(New Manag4) Survey Form - Page 1 <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 /> Site Suffix: - <br /> Z � � � � ® I ® 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 J <br /> ) Inspected By Inspector <br /> �, l —zat_V l/Scn� �t S <br /> Physical Addr <br /> ss-- <br /> 4 — ( &co4m- <br /> C Inspection DateI G / Q / 1 o <br /> Time In Time Out <br /> Business Rep Title `` O AM f� Q AM <br /> G 1 l�(' O PM v l� ® PM <br /> �. tai S �tPi c=iJV O W Yl - <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 /> f 4& Active • Passenger ® Generator ! Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 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 /> • 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 /> I V A i 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 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 /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 1010 Other: § <br /> Comments <br /> 1 i r -s pec&c1y� 6-yN Imo►°� C�C :n G�.,.,�c <br /> Inspection Form Included: Q. 4 <br /> Comments Included: ® z3 <br /> Rusin s Rep s S nature Phone Number spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 1 62081 <br /> X �a <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy <br />