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Waste Tire SL_ y & Inspection Repon, inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I1 - 1140852 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 0 _ I Inspection Type (Fill one) <br /> Site Suffix: I# Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: wr1 -(3%w Lyy Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam/e� Inspected By Inspector <br /> Physical Address <br /> JInspection Date c) <br /> LCVyY�n�l C� S zZ-`t LJ J <br /> r I Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ® PM 0 © 0 PM <br /> Operational Status Tire Type Business Role �torage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � <br /> ® Active ® Passenger 0 Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GAS ® Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ® 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 ® Hauler Q Agriculture Q Shredder ®Other11� _ l!�/t'�e�� (,i(.V"-r <br /> 1"1Gror <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> -- �_ — _. <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 I 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 1 Q 1 Other: § <br /> Comments <br /> Inspection Form Included: <br /> � � Cz�9 �Gs�o623 <br /> Comments Included: ------ <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK r Correct: Incorrect: X PILIE1 1 62081 <br /> —_ - - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />