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Waste Tire Sup y & Inspection Report nspection Report Number ■ <br /> ��WMB1California(New04/04) Survey Form - Page 1 I 1 - 1127742 <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � >� � _ ® � Inspection Type (Fill one) <br /> Site Suffix: g A Routine O Re-inspection O Referral O Observation <br /> Local r`r� If Referral,choose referral type(Fill one) <br /> Identifier: SQA � �1 fl �.�C, YA O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> ' <br /> Physical AddrbsC�P s_" cc,S _ <br /> � 9 0 <br /> I <br /> Time In Time Out Date � b q <br /> s4 0 (, �b� (A �5 X0(0 � ® I <br /> Business Rep Title ` I O O AM i "I , ® PM <br /> . PM I � V <br /> ` C — — <br /> -J—Uu-0 Jln�-- - --- �Anm-Vcr -- <br /> Operational 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 Passenger (S Generator • Outdoor <br /> O O Closed O Altered <br /> GPS Latitude O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude — O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> i Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT STATUS <br /> V , <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> i O 14 CCR§18it in Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> ' 4 COW-f <br /> n - -- - - -- <br /> i0�_o►4�oqS 0�-���:� -CO <br /> V�_S;_A.F"�I-�►' � I�w el_ <br /> :Inspection Form Included: <br /> Comments Included: O <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: <br />