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g@ a Waste Tire 90y & Inspection Rept p p <br /> . ort ns ection Re ort Number <br /> !fl State B California Survey Form - Page e 1 Il - 11412 91 <br /> CIWMB 181(New nage) ry <br /> California Integrated Waste Management Board y <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Ins ection Type Fill one <br /> Site Suffix: (� - <br /> 3 `-� 1 `�-� ® Routine yp0 Re-inspection 0 Referral 0 Observation <br /> Local , ,`�f M If Referral,choose referral type(Fill one) <br /> Identifier: V t ' l C hJl l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> <_�CfWQ!S Inspected By Inspector <br /> Physical Address 0 <br /> 0 Y4 <br /> �1 � Inspection Date C / / � cl <br /> CopTime In Time Out <br /> Business Rep Title 0 AM /' O AM <br /> l 0 PM 1 D /V a PM <br /> 1�u CLAY" - <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 /> 1 / ® Active 0 Passenger Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler 0 Indoor <br /> 0 0 Inactive &Truck <br /> Longitude - 0 Planned 0 OTR End-Use ® 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 ® Other -I�'� I �� /�►I� �S �rS <br /> Part B -Inspection of Waste Tire Dealer Generator, Hauler and End-Use Facilit ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 DateG ` i <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 L0_In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> { <br /> Inspection Form Included: <br /> Comments Include - -! � <br /> 44knessp's igna ure Phone Number In a or's S' ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X XJLJEI 111 3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C"Ad <br />