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Waste Tire E ey & Inspection Repc Inspection Report Number ■ <br /> State California Survey Form - Page 1 I 1 - 1127724 <br /> CIWMBB 187(New 04104) <br /> California Integrated Waste Management Board <br /> Part A—Survey _-- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- y Inspection Type (Fill one) <br /> Site Suffix: ` -7 - -( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ��� ��� � •� C'"�'' � If Referral,choose referral type(Fill one) <br /> Identifier: ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C� Mct� e� - l o <br /> Physical ddress � � <br /> / I <br /> � �`,� Inspection Date <br /> p <br /> {C(Iq �C�'L �` � Time In l Time Out l <br /> Business Rep Title ,/� O AM I Q AM <br /> I ' 3 0 . PM Y 4/ 0 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 /> f f ®Active J*Passenger Is Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive i ® Truck <br /> Longitude - Q Planned j 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 ® 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 /> j V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 10 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 /> I <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 Q Other: § <br /> Comments <br /> N00�7'Ylf- I+ l7 ' <br /> 015 <br /> Inspection Form Included: Q / 7 <br /> Q <br /> Comments Included: - --- --- U-[�_ _ <br /> - <br /> - - <br /> Bu i s R Signature --_Phone Number In c r_' nature Phone Number- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect P( ( <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy:LE ■ <br />