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Waste Tire Sui .ey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB eSurvey Form - Page 1 <br /> I 1 1088320 <br /> California Integrated Waste Management <br /> Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: - Q L 411 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� ��� �/n, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> V ic-, Ir3 �1 - 1 C) i AG A-lic nby1 <br /> Physical Address <br /> ` /� Inspection Date <br /> � SC�� Time In Time Out [ C! <br /> Business Rep TitleO AM ? AM <br /> oZ L! ® PM �.7 � � � PM <br /> �G�l���l l �YIC Operational Status6 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered /U'1A !/t <br /> GPS Latitude A11A Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude – Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that 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 * 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 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 <br /> Q O 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § --- <br /> Comments <br /> toe — <br /> Inspection Form �nc <br /> ncluded: �Zv <br /> Comments lud 04 CD <br /> q <br /> Busine Rep's Sig'&a?u6 Pho a Number I s or' Si ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: i 62081 <br /> - — � _ i " <br /> White Copy:CIWMB Yellow Copy:Operator Pink C :L ® ■ <br />