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pection Report Number <br /> Waste Tire S sy & Inspection Report - - <br /> State of California <br /> CIWMB1811st(New <br /> Manag ) Survey Form - Page 1 I 1 - 1141300 <br /> California Integrated Waste Management Board _..._.—._. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> (Business Profile inspection Details <br /> TPID- 1 .1! Inspection Type (Fill one) <br /> Site Suffix: - I15I _ ... z 1 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 1. 1 ` G(�.) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 1`N p <br /> Physical Address �L`'' 'J f i✓ I - <br /> Street <br /> Inspection Date I71 <br /> L <br /> e r Time In Time Out <br /> ��;7v St�fiv 1 .,oda t: <br /> Title 0 AM <br /> > 1O <br /> Business Rep �u�� � � O PM 0 AM <br /> O PM <br /> �e <br /> D' ' ( <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Wht7ie/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O., 0 Closed 0 Altered <br /> GPS Latitude I I 0 Hauler 0 indoor <br /> �_...- 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 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 <br /> - - ------ — 0 Notice Of Violation 0 Extension <br /> 3 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 /> 0 0 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 0 In Compliance - No Violations <br /> 0 0 Other: § _...... <br /> Comments II i <br /> LZ <br /> Inspection Form Included: 0 `' -- <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspe9tor's Signature Phone Number <br /> '� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X `fi X Xfi'M $ 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />