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Waste Tire Sui „ey & Inspection Report Inspection Report Number ■ <br /> CWWB81'fornia <br /> (New 04/04) Survey Form - Page 1 Il - 1143581 <br /> California Integrated Waste Management Board ! J <br /> Part A-Survey _- B_L_U_E_ OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- © Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> LocalJ �� /•_ If Referral,choose referral type(Fill one) <br /> Identifier: }. �i��l � LN1. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name. Inspected By Inspector <br /> Ph <br /> rl L Addr ss �mpan L, <br /> t7)Ztl7I bel <br /> Inspection Date 4-1 � g � 1 <br /> CA al�� Time In Time Out <br /> Business Rep Title Q f� ir. Q AM ®AM <br /> J ` O PM 0 PM <br /> - <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 /> 10- ® Active ® Passenger 0 Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> 0 0Inactive 10 Truck Longitude - End-Use o Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® 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 I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days j (Required for NOV or EXTJ <br /> O 0 <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 /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q Other: § <br /> Comments <br /> (Inspection Form Included: Z- ' ! - I <br /> Comments Included: : - -- <br /> L - -ja- -Yid-66 73 <br /> BusmZs "`s S) nature Phone Number In or's ure Phone Number <br /> INSTRUCTIONS ON BACK Correct:(' Incorrect: X VI #� , 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />