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Waste Tire Sul, „ey & Inspection Report inspection Report Number <br />,. State CIWMB California I 1w 04/04)— 114 0 8 51 <br />California Ine grd Waste 181 eManagement Board Survey Form - Page 1 <br />'art A- Survey BLUE OR BLACK INK PEN_ <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: i S 1 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: yv 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name <br />//�' � t Inspected By Inspector <br />Von -1eA­' G, - / Dk)-tomPhysical Addr3 C% — { <br />6A. 9 5,2 I <br />Business Rep Title <br />i o I"1 u�Y�-i d1 G ro <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />0 New Tire Dealer <br />0 Auto Repair <br />0 Used Tire Dealer <br />0 Auto Body <br />0 Service Station <br />0 Hauler <br />Inspection Date <br />fI / <br />(�J) <br />i '1. / <br />i <br />Titne In <br />0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Time Out/ <br />0 <br />/� <br />Q AM <br />z Q AM <br />J <br />{ <br />® PM <br />0 <br />® PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />0 Passenger <br />0 Generator <br />® Outdoor <br />0 Closed <br />0 Altered <br />0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® in Compliance - No Violations <br />0 <br />0 Other: § <br />0 Hauler <br />®Indoor <br />0 Inactive <br />® Truck <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container. <br />® Trucking Fleet 0 Government 0 Retreader <br />0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Agriculture 0 Shredder 0 Other <br />0 Dismantler 0 Tire Derived Fuel <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />0 <br />- ---------- ----------- --- <br />0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />0 <br />0 PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m / m / m <br />0 <br />0 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />0 <br />0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred f CIWMB Enforcement <br />0 <br />0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® in Compliance - No Violations <br />0 <br />0 Other: § <br />- .. <br />Comments <br />l[C17wzrz Q "OA cl <br />Inspection Form Included: 0 <br />Comments Included: <br />Busine Rep's Si a rf <br />INSTRUCTIONS ON BACK Co ect: <br />White Copy: CIWMB <br />1: � � __ f ) L/68-04,2_ <br />Pho er Inspector's Signature Phone Number <br />62081 <br />Incorrect: X X A M L 1 3 <br />Yellow Copy: Operator Pink Copy: E <br />