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® n;= Waste Tire Su. .y & Inspection Report , Inspection Report Number <br /> State of California <br /> CIWMB 11 114 0 7 8 8 <br /> California Integrated WaseeManagementBoard Survey Form - Page 1 <br /> Part A-Survey BLUE_ OR BLACK INK PEN_ <br /> Business Profile Ins ection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: tcc Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address <br /> ✓ �l�l'!4'frJIG <br /> Inspection Date <br /> �✓L�� CiS 33 D Time In Time Out <br /> Business Rep Title ®AM ®AM <br /> 1 v 3 C) Q PM 3 Q PM <br /> - - -- -- - - - - - - - ---- ---- Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � j �i <br /> ®Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 4P Truck <br /> Longitude - Q Planned j Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q 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 <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Fn / m / m <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 EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <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 /> CommentsCA, 7KW <br /> Inspection Form Included: QI <br /> Comments Included: ®, -- <br /> Business Rep gna Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:I* incorrect t l X I A p f 213 620811 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C VL © ■ <br />