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Inspection Report Number <br /> Waste Tire Su my & Inspection Report <br /> iif Cgrated 1steManage) Survey Form - Page 1 1 7 - 1 0 7 9 1 7 1 <br /> State of California <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ! 3 D _ D / Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `f aq �h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date 2 2- <br /> Time <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> Q PM Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f 2 v (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active ! Passenger 0 Generator Q Outdoor <br /> Latitude <br /> O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 40 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 REQUIREMENT, <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Not li ice Of.Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ad <br /> fe <br /> line <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements j7LL] <br /> / 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 eguired for NOV or EXT) <br /> 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 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 ations <br /> Q Q Other: -- <br /> Comments Jn/s,� 7'o�'i7 <br /> dot e.A <br /> !'r)co- Gt.�i �P •w �t. �t�.ce.�t-- �-it..��i--� 07,c S.�e <br /> Inspection Form Included: Q i� <br /> Comments Included: s 's <br /> s e SI nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BAC IEIXIAIMIPILIEI 1112n3 62081 <br /> Wh e Copy:CIW Yellow Copy:Operator Pink Copy:LEA <br />