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ee- <br /> Waste Tire Su, Bey & Inspection Report Inspection Report Number <br /> "a CIWMB 81California <br /> CIWMB Survey Form - Page 1 Il 1143837 <br /> Califomia Integrated Waste Management Board ! — — — <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 n Inspection Type (Fill one) <br /> Site Suffix: �� �> V 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 'n "/I If Referral,choose referral type(Fill one) <br /> Identifier: ` \ c��j� �� (mil,r 1, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ((( <br /> Inspected By Inspector <br /> Physical AddressZ_zll t� (j'121t <br /> � Inspection Date -_, � � f_ � '� <br /> � � �C` t er l t <br /> Time In Time Out <br /> Business Rep \�� Title 0 AM 0 AM <br /> 0 PM PM <br /> —� Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) � � <br /> ®Active Q Passenger IS Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O 0Inactive Q Truck <br /> Longitude - Q Planned ® OTR 0 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 O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder ® Other L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 FXT) <br /> O O -- <br /> 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 f CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O 0 Other: § - <br /> Comments - <br /> G � - <br /> /?j 23YI.S �07Gc S �C7ylL' .' <br /> Inspection Form Included: Q <br /> Comments Included: Q ---- — qZ S="_�o old$-5/6?-Q <br /> Bu ss s Signature__ Phone Number or ature Phone Number <br /> - -- — 1[:C:o:rrect: <br /> - 62081 <br /> INSTRUCTIONS ON C 0 Incorrect: X V A P _ 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pin Copy: ■ <br />