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'i Waste Tire Sur . ey & Inspection Report Inspection Report Number i <br /> CIWMBCalifornia <br /> 81(New 04/04) I 1 - 114 3 6 6 3 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �j Inspection Type (Fill one) <br /> Site Suffix: ,� © / Ly g ( f I* Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Spm t/OQt [rim Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addrdyss - / ..S'U84V <br /> 3,2,0 W"A <br /> Inspection Date 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM / O 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 /> f *Active 40 Passenger Generator ® Outdoor <br /> GPS Latitude 0 Q Closed Q Altered Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ° End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 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 /> _- <br /> V AIHAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 I / M / m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 EX7) <br /> Q ° <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 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 I° 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: `209 <br /> p . °' - _� <br /> Comments Included. Business s Signature Phone Number Inspector sSignature - Phone Number <br /> --- - i - <br /> INSTRUCTIONS ON BACK <br /> Urrect 4D Incorrect: c, 1 'l'f• V X ! 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y L A ® ■ <br />