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Waste Tire Sui y & Inspection Report ispection Report Number <br /> State <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1140571 <br /> CIWMB 181(New nage) Y ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey_ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r♦ 4 j � � $ � - / Inspection Type (Fill one) <br /> Site Suffix: 3 -1 o ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: szt*, )U�N-, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name J Inspected B <br /> r_ P y Inspector <br /> ' <br /> I Physi <br /> cal ddress <br /> 3�s Ave, <br /> Inspection Date I Z 1 0 <br /> Time In Time Out <br /> Business Rep Title ® AM Q AM <br /> O PM 2 4 O PM <br /> - - Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) (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 /> Latitude 0 ® Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> 01 - <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 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 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 I Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 f 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 <br /> in Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Otit .ti'ls► f 1 C pic_Cf-ii-cv, cf:,t&d --_`f"1�-�. 1 acu-' <br /> ,Inspection Form Included: Q <br /> o C3 <br /> Comments Included: <br /> I Business Rep's Sign mber spector's SignaturPhone Number J <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A�' , ,X A- FT <br /> -- p 3 <br /> _ 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:L <br />