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, E <br /> ■ = Waste Tire Sul► ey & Inspection Report Inspection Report Number ■ <br /> CIof California 04,04) I 1 — 1143479 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey _ --_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(/l� 0 ��A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ?OAV� k;0 _ l <br /> Physical Address o <br /> � <br /> C n 9ci,^s Inspection Date ` l O <br /> b0N .LJ✓ <br /> Time In Time Out <br /> Business Rep Title O AMO AM <br /> !] PM � Q O 0 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 /> �--'/ Q Active ® Passenger ® Generator Outdoor <br /> O ®Closed Q Altered <br /> GPS Latitude 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 A Other P�t4�i� GL�11h�'U�kle_r <br /> -- __ ._.._.._._. <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 i Date / 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 EX7) <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 Q Other: § <br /> Comments XN AO s t <br /> No U 1 I 5 b6L1 s o+ c. q ck . <br /> Inspection Form Included: Q �Sign <br /> _-7 n 1 <br /> Comments Included: ( O <br /> -- - <br /> siness RePhone Number Inspect Signature hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect X �/ � X A P 1 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C A <br />