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s <br /> Waste Tire Su$y & Inspection Report Inspection Report Number ■ <br /> State California I 1 - 1140811 <br /> CIWMBB 187( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business PID Profile Inspection Details <br /> Type (Fill one) <br /> Site Suffix: 37 0 .- 7 Q <br /> ® Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName / Inspected By Inspector <br /> C� 1 <br /> Physical Address / Llr ` <br /> 102- 1 <br /> /, Inspection Date ft / <br /> S�Ci�fTJl'` CA (�vZ��J 7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 00 . 4 ® PM U 3 az c) ® PM <br /> Operational Status!i 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> 0 Closed Q Altered <br /> GPS Latitude - Q Hauler � Q Indoor - <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR - I Q End-Use Q 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 /> 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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS 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 / / 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 (� In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q yi <br /> Comments Included: ® /v <br /> Business Rep's Signatu Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct #ncorrect _'-fes �� s2os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: A <br />