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Waste Tire SL_ _ .sy & Inspection Repoi _ Inspection Report Number ■ <br /> r11 State of California <br /> CIWMB 181 04104) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 Il - 1143977 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ;iness Profile Inspection Details <br /> plp_ ` � � � � � - O I Inspection Type (Fill one) <br /> Site Suffix: { tj ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q� ,ocu _lm � L� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> cckq -Izj <br /> Physic. Adder ss 3 9 - hy�vn We� <br /> �.� S•ec�i,i u l cam. <br /> U Inspection Date 5l Z <br /> rl un CA b Time In Time Out ! �J <br /> Business Rep Title T, p� O AM J O AM <br /> I Z ' V CO ® PM Z ' 6 O 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 /> f r 11/V) Q Active 0 Passenger a Generator ® Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 1 Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet ! Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> .� 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 Facility ENFORCEMENT STATUS___--_ - <br /> ------ ------ <br /> 1 V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 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 Q 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 /> L.. ection Form Included: <br /> p O <br /> Comments Included: <br /> Business Rep's Signature Phone Number I p S• nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® 0 <br />