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Waste Tire Suoy & Inspection Report Inspection Report Number <br /> i� State of California Survey Form - Page e 1 Il - 1141348 <br /> CIWMB 181(New nage) g <br /> California Integrated Waste Management Board `� <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> TPID- ` Inspection Type (Fill one) <br /> Site Suffix: '536 s V r� 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local U �p M If Referral,choose referral type(Fill one) <br /> Identifier: w� t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> O-P, tio - 1 O ftm�Lfc <br /> Physical Address <br /> 's. <br /> Inspection Date LA <br /> j Time In Time Out <br /> Business Rep p Title P / ®AM l `� L ®AM <br /> 7 �Q r5 oIS'd-!I f�lbn MV f 3 0PM- I —` v CJ 0 PM <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 /> 0 Active O Passenger ® Generator Outdoor <br /> � O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive 0 Truck <br /> Longitude — O Planned O OTR 0 End-Use O Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair O Trucking Fleet O Government 0 Retreader ___ODismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O 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 /> 'O Notice Of..Violation OExtension <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 i 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 <br /> 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 O 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: § - --- - p <br /> Comments - - a—nc C. — <br /> --col 1?0 I-1 C,J - - - <br /> �Q <br /> Inspection Form Included: OI q <br /> Comments Included: <br /> Phone Number - In cos tul _ Phone Number J <br /> ............... 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A P I�2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C <br />