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Waste Tire S011ey & Inspection Repo Inspection Report Number <br /> � <br /> •L State of California <br /> CIWMB ( ew 04104) <br /> I 1 - 110 8 4 3 7 <br /> California Int grat dtWaste Management Board Survey Form - Page 1 <br /> Part A- Survey ---- BLUE OR BLACK INK PEN <br /> --- - <br /> Business Profile Inspection Details <br /> TPID- r Inspection Type (Fill one) <br /> Site Suffix: , (' - O Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: C )4 A � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> . __.. - <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L�....._1�-� `��f�l ill �� i I� i�'• �- � L_._..� ._.:_.._ __..__. <br /> Inspection Date <br /> C{, State Zlp Cade Time In Time Out <br /> Business Rep Title O AM Q AM <br /> _.. <br /> O PM PM <br /> Operational Status- Tire Type <br /> Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �r`° Qre Qli�t h0�1r✓PTE) <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Latitude Hauler Indoor <br /> GPS �j .LLJ I <br /> _ O O <br /> — �.�__..._"_�� o <br /> O O <br /> Inactive Truck <br /> 1. .—tl...__) 1 I <br /> Longitude – Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all tha;apply) -- <br /> Q New Tire Dealer Q Auto Repair Q 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 ENFORCEMENT STATUS <br /> V A HAULING 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 O PRC,§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / <br /> Q 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 /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 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 Q In Compliance - No Violations <br /> O O j other: § <br /> Comments <br /> Inspection Form included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �� 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A ,. > AW,, P• L'�I t <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />