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Waste Tire Survey & Inspection Report Inspection Report Number <br /> k State of CIWBCalifornia <br /> ew 04/04) <br /> Califom> Int grated Was181 te Management Board Survey Form - Page 1 1 2 <br /> - <br /> 100 65 8 3 <br /> Part-A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` c> 3 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: a V� >,t>6L ` ;;, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l/ <br /> Inspected By Inspector <br /> Physical Address <br /> c--+ Inspection Date j <br /> Il Time In Time Out <br /> Business Rep Title Q AM <br /> T �r er PM ® PM <br /> - - Operational Status Tire Type i Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> n ® Active ® Passenger ® Generator 0 Outdoor <br /> > > <br /> 0 Q Closed 0 Altered <br /> GPS Latitude 0 Hauler 4P Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> ® - ® P � 9 � 0 Retreader - 0 Di - ` - - <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Auto Repair Trucking Fleet Government Dismantle 0.Tire.Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ® Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- ---------- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / M.'�' <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> -(Required for OV or <br /> 0 I 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �}Re�#erred CIWt orcee <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities rL, <br /> 0 ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators T `� <br /> f ®In Compliance - No,,Violations <br /> 0 0 Other: § i - - -- ----- <br /> Comments <br /> Inspection Form Form Included: D .-, <br /> Comments Included: 0'I ---- -- �. 1--�-/ --`-1 - - - --- - <br /> - - - --- - - <br /> Busines Re s Signature - Phone Number I pector's Signature Phone Number <br /> [ i62081Incorect:X f �INSTRUCTIONS ON BACK !Correct. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />