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l <br /> Waste Tire Sup,..--y & Inspection Report Inspection Report Number ■ <br /> CIWMB181fornia <br /> (New 04104) I 1 - 114 3 510 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> A--Survey BLUE OR BLACK INK PEN <br /> Part <br /> Business Profile Inspection Details <br /> TPID- H I _ © I Inspection Type (Fill one) <br /> Site Suffix: r 3 l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ l If Referral,choose referral type(Fill one) <br /> Identifier: S 4� \ OC-�u1 n CUQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Cv J Inspected By Inspector <br /> CCA. Gf C\%, r,,, r Ice, Sed V i <br /> Physical Address <br /> QA, <br /> Inspection Date <br /> (A <br /> Time In Time Out <br /> Business Rep Title 0 AM AM <br /> V Q 0 PM ` I I O PM <br /> - - - - - <br /> c� �� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> �e sl Slx m c.I��'` tc�os- <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> � � a <br /> 0 Active Q Passenger ®Generator S Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 Other �� /L'1�S�r 1�e(�a►fS <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 11 A HAULING AND MANIFEST REQUIREMENTS <br /> Q i Q - Q Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> I <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. 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 EXE <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 Q Other: § _ <br /> Comments n t � P , 41(��+Irv— <br /> N O vii\r��ti w, s s -- <br /> Inspection Form Included: Qi -- <br /> Comments Included: --- �/`' 0 -. Sff Oiz�� <br /> Bus ess Rep's Si ature Phone Number In pe is Signatu e _ _ hone Number <br /> - 62081 <br /> INSTRUCTIONS O ACK Correct: Incorrect: X y �/ X +� 111 213� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: E ® ■ <br /> J <br />