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j. Waste Tire S & Inspection Repo ection Report Number <br /> ■ <br /> On i31A CIWMB 81i(New04/04) Survey Form - Page 1 I 1 — 1127675 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q ^ � - O Inspection Type (Fill one) <br /> Site Suffix: `��,(` 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: n- � �� ��.+r b Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �,,, Inspected By Inspector <br /> &al ftr_ � %terns �f 1- �f� <br /> _Address 5 l Q A I;�a,S 0 Aen 6,� <br /> �3_7W Mufl66 4"r'- J '6 <br /> Inspection Date <br /> (��(/� C•lf Time In Time Out I <br /> Business Rep // Title f z 0 AM ? 0 AM <br /> O PM � Z ' J D ®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 /> ®Active Q Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q HaulerIndoor <br /> O Q Inactive (6 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility iENFORCEMENTSTATUS <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 /> 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 / 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 I 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 /> Q 1 Q Other: § <br /> Comments ,f <br /> Inspection Form Included: Q n <br /> Comments Included: Q " 4 `��� :/—,z <br /> Business Rep's Signature Phone Number Ins cos ' nature oe Phone Number <br /> INSTRUCTIONS ON BACK Correct:0-Incorrect I P 1 62081 <br /> X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co V A ® ■ <br />