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Waste Tire Suy & Inspection Repofornia nspection Report Number <br /> _rr <br /> CIWMB 81'(New 04/04) Survey Form Page 1 I - .1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ 1 BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: f Gi' +� r <br /> — 7�Routine Q Re-inspection Q Referral Q Observation <br /> Local ,�-- -• If Referral,choose referral type(Fill one) <br /> Identifier: C­7:�'� � ^Y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street <br /> f Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title OmAM• m0PM IT—] 0P0 AM <br /> I �i r <br /> (� Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I�W (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> W Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government (5 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 I �. I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 m / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of.Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§.18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 In Compliance - No Violations <br /> Q Q Other:-§ <br /> Comments <br /> Inspection Form Included Q rte ' <br /> Comments Included: Q Z.- <br /> Business <br /> ._Business Rep's Signature Phone Numbe-r�/ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X)�� EJB; I �? ,� 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S <br />