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r: Waste Tire SA & Inspection RepAft;pection Report Number <br /> State B California I 1 - 1127679 <br /> CIWMB 181(New Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Surv_ey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / � •� _ o i Inspection Type (Fill one) <br /> �Site Suffix: lJ l e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ,/� <br /> ► 1 l_.�l/ f`zf� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y ) Inspector <br /> Physical Address r 1 �� LLC- <br /> - 1 Q l l <br /> Inspection Date I / l / ] Q <br /> Time In Time Out <br /> Business Rep ��/ Title 0 AM OAM <br /> ? lC� [ ® PM2 LJ ®PM <br /> 7 <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 /> ®Active Q Passenger ® Generator ® Outdoor <br /> Latitude <br /> Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> Q Q Inactive ® Truck i <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR � <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> i® 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date Mm / <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 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 Q In Compliance - No Violations <br /> Q Q Other: § j <br /> Comments <br /> jInspection Form Included: <br /> Comments Included: ll® <br /> usine s Signat Phone Number InOe or's ignature Phone Number <br /> INSTRUCTIONS ON BACK Corr Incorrect. i , PI Z g1� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA _, t ® ■ <br />