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0921009024.9 <br /> =e1B Waste Tire Survey & Inspection .Report inspection Report Number <br /> State of Californla <br /> cFWMB 1stNe. <br /> Manag) Survey Form - Page 1 1 2 - 1 0 7 9 3 4 0 <br /> Callfomia Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: � �� O ` •Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: . Sup u,O Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U - <br /> Inspected By Inspector <br /> QTN bb,_oA_ _!4_Qju1)A4V' <br /> Physical Address sy <br /> - <br /> Street Date <br /> Inspection <br /> Isal P <br /> Cit y0 State ZIp pude Time In Time Out <br /> .Business Rep Title 5 O AMQ AM <br /> APM ® ' � I* PM <br /> _Qg <br /> A, . <br /> St k D_Q_ �tm�c�a�_(hung_erJ - <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Ila0 Active Q Passenger •Generator •Outdoor <br /> l I (�I0 Q Closed Q Altered <br /> GPS Latitude �I— I , I� Q Hauler Q Indoor <br /> _I 0 Q Inactive 0 Truck <br /> Longitude - I I �I I I I I 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 /> r t <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 EN FORCEMENT STATUS <br /> V ; A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / / m <br /> Q 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 (Required for NOV or EXT) <br /> Q O 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 /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ----o_S_(Lk As— <br /> obe.I V�nitaa.5� owc_ b '1 nc��v iAuls 4-a_Se <br /> Inspection Form Included:!ON <br /> Comments Included: — �✓ - - r+/— ` -- ( O "�-�I� <br /> Business Rep s _at a Phone Number Insp tor's ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS BACK Co rect: Incorrect: E X A M P L E 1112 3 <br /> White Cop :CIW Yellow Copy.Operator Pink Copy:LEA <br />