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Waste Tire & Inspection Repc.. _ Inspection Report Number <br /> ■ S�i9� State of Cali181 <br /> forniaCIWMB y T — ■ <br /> Calif Integrated Was eeManagelment Board Survey Form - Page 1 i 1 1143636 <br /> Part A- Survey- -- BLUE OR BLACK INK K P_E_N <br /> Business Profile Inspection Details <br /> TPID- � � � � Inspection Type (Fill one) <br /> Site Suffix: ` O O Routine 41 Re-inspection Q Referral O Observation <br /> Local �.)l�l� \ rV ' If Referral,choose referral type(Fill one) <br /> Identifier: �-L� �� ��j��¢Zi Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> fo'S75' coliqay) LL C <br /> Physical Address S <br /> a I. <br /> ,),1113' t c.VIP O5c, P.L <br /> �, �*� (,0. Inspection Date � � � � � l <br /> 1��5' Time In Time Out <br /> Business Rep Title C� • AM !l �:AM <br /> Q PM Q PM <br /> - --— ---- -- - -- — -- — Operational Status Tire Type Business Role Storage Type <br /> j <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I67 <br /> 9 Active Q Passenger ®Generator a Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler ® Indoor <br /> O O Inactive ® Truck <br /> Longitude — O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O 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 <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Q II PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O . Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / M <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> SLS-- Comm <br /> ,Inspection Form Included: Q ,r <br /> Comments Included: ` <br /> "Ines s Rep'slire Phone Number _ in ec or's i ature _ _ Phone Number <br /> INSTRUCTIONS ON BACK !Correct: Incorrect: , 62081 <br /> T�1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy ® ■ <br />