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Waste Tire Sui - Jy & Inspection Report Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 0 7 0 7 <br /> grated 1st(New <br /> Manag4) 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- / _ O / Inspection Type (Fill one) <br /> Site Suffix: Routine Re-inspection Referral <br /> � Q P Q Q Observation <br /> Local 7 If Referral,choose referral type(Fill one) <br /> Identifier: Jd7lr � (/��«e%7 — 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 <br /> Time In Time Out <br /> Business Rep Title 0 AM ) `] Q AM <br /> 7 O PM / Z / ® PM <br /> 44 <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 /> t Active ® Passenger ® Generator out <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer • Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 <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. I 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 / 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 0 Other: § <br /> Comments t% cvi <y <br /> Comments Included: <br /> Inspection Form Included: Q� <br /> o ments Inclu e Q - - - - - - - - <br /> s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect �;. wl 1 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py: ® ■ <br />