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jjWaste -y & Inspection Rep�,it inspection Report Number Tire �.�� ...State California Survey Form - Page 1 I 1 - 1140679 <br /> CIWMBB 181(New 04104) <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: / �-, a 5 73 l -7 Q Routine ® Re-inspection Q Referral Q Observation <br /> Local �^ , , If Referral,choose referral type(Fill one) <br /> Identifier: ��L�� kL�{��/� ( ll✓� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> I Inspected By Inspector <br /> C.k; -'re, <br /> _ <br /> Physical Ad rd ess 1 01 <br /> Inspection Date O �/ <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Z d Q 41 PM 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 /> 0 Active 0 Passenger 0 Generator O Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 4111 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 /> V A 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 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 / 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 40 In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> Inspection Form Included: Q' �SS <br /> Comments Included: * - — --- - - <br /> Business Rep's Signature Phone Number In pe s S' n ture Phone Number <br /> INSTRUCTIONS ON BACK FCorrect: Incorrect XI s2081 <br /> Gf% X F � Ti23 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y: ® ■ <br />