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Waste Tire Su- ,ey & Inspection Report Inspection Report Number ■ <br /> orr State CIWMB California I 1 - 114 3 8 4 5 <br /> Californialntegrat dWasteManage181( ew 04/04)mentBoard Survey Form - Page 1 <br /> Part A-_Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 4q 3 3 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Bushiness or Facility Name Inspected By Inspector <br /> Physical Address <br /> ........... <br /> CJY[.� bvtL` <br /> C5c�,'S7 Inspection Date <br /> Pon Time In Time Out <br /> Business Rep Title O AM Q AM <br /> PM 40` 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 /> 13 ®Active Q Passenger ®Generator • Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - ® OTR Q End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 ® Other �f�(:.( <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 /> I <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 <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 /> Q Q 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> 010 1 Other: § <br /> Comments <br /> "Uva <br /> 'Inspection Form Included: Q <br /> Comments Included: I l - - - — - -z&-/— - <br /> Busin ss ep s 'L Phone Number ect Signa re Phone Number <br /> - - - - - <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect ^/ A ,+ P114 i 2 3 s2os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink ® ■ <br />