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Waste Tire Su. - _y & Inspection Report ispection Report Number <br /> ajs' State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I1 - 1140864 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey _—_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ZT 3 Z — Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Q <br /> Identifier: V_ cwvwl� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I f Inspected By Inspector <br /> y iress J 31 /ry �" �? <br /> Physical Adf �J / — t oert�_" <br /> I Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title 6 ,7 � Q 0 AM Q 0 AM <br /> e3 <br /> �C ® PM ® PM <br /> pc t,`, V4r1&.cXt �cnr► 1 - �- _ -— — — - ----- <br /> — — --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) u (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -� 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned ® OTR 0 End-Use 0 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 ® OtherT <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 7 <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 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 Date m / m / m <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 <br /> in Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: ®� I � <br /> LBusiness Rep's Sign ture Phone Number spectoes Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X I 1 r,XI ACop :LLE 1112131 <br /> -- rato <br /> White Copy:CIWMB Yellow Copy:Operator Pink <br />