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Ins ection Report Number <br /> � Waste Tire S y & Inspection Repori�: p p � <br /> t�i96Z9 State CIWMB f81 Waste <br /> California T i — 1088350 0 ® O °� <br /> w 0410 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 1 1 ® ® J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business P"rofile `� ` i — <br /> - 'r j Inspection Details . <br /> TPID- Inspection Type (Fill one) <br /> Site SuffixL'��j ( / - _� Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _A If Referral,choose referral type(Fill one) <br /> Identifier: / , �f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> .^ <br /> cl <br /> Physical Address <br /> / I - <br /> (Street i t , Inspection Date a <br /> r <br /> l'r!t ( State ZIP Code I Time In Time Out <br /> Business Rep Title 0 AM <br /> PM —1 v 0 PM <br /> Operational Status Tire'Yjlpe Business Role $fit rage#ype <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fil,I,all'hat apply) <br /> Tire Count(Wholel(�T <br /> „•„„ !r•, Trr„ � „ ,, 0 Active 0 Passenger , Generator Outdoor <br /> Closed Q Altered <br /> GPS _T” <br /> Latitude 0 Hauler Q Indoor <br /> 0 Inactive Q Truck <br /> �— O <br /> Longitude — � 0 Planned Q'OTR 0 End-Use Q Container <br /> Business Type (Fill atl that apply) _ -- <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet I Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 O 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / 0 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 0 Other: § — - <br /> Comments <br /> 'Inspect! f FOrm') <br /> Com mtS Include 01 -^ �_••.” a c.?n, ,�^ ' r w a d9 t rte" s , t + �'r s <br /> _ BITS{r1eSS Repsr'"_ 4111jdi,11'e_' uFY ^^,M,ey,pb dn '..,. .ti', A .. I4_,�h .: '1.; <br /> INSTRUCTIONS ON BACK Correct:, Incorrect: P �E� 1 62081 <br /> r <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />