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Waste Tire Surdvl & Inspection Report iispection Report Number <br /> State of California I 1 - 1140802 <br /> CIWMB181 <br /> Waste <br /> eMana14) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L D / Inspection Type (Fill one) <br /> Site Suffix: I Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local . If Referral,choose referral type(Fill one) <br /> Identifier: C /Y�+ 607,(y, r- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address / - U <br /> Inspection Date vZ �} / o <br /> Time In Time Out <br /> Business Rep Title 0 AMO AM <br /> ® PM 3 O PM <br /> -— ----- r -- ----- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> • Active ® Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned I♦ OTR 0 End Use Q Container <br /> Business Type (Fill all that apply) — <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 0 Notice Of Violation 0 Extension <br /> 0 0 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 / m <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/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 /> Inspection Form Form Included: <br /> Comments Included: 61 <br /> ' ~ e <br /> -!L� <br /> one NumberQ � <br /> Business Rep's Signature nne ture Phone Number <br /> - - -- - - -- - — <br /> INSTRUCTIONS ON BACK Correct Incorrect 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y:L ® ■ <br />