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Waste Tire Survey & Inspection Report Inspection Report Number <br />State <br />CIWMB <br />Survey Form - Page 1 <br />CIWMB CaliforniaCal fNew 04/04) y 9 11- 1143451 <br />California Integrated Waste Management Board <br />r%_. A BLUE OR BLACK INK PEN <br />-01L r- aJUN YGy--- <br />Business Profile <br />Inspection Details <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />TPID - <br />Site Suffix: r 1 % 4-1 Q <br />Local C _ <br />Identifier: �� <br />Business or Facility Name <br />Inspected By Inspector <br />�tcc cvcL-'SV%' <br />Address <br />- 1 <br />Physical <br />a t <br />Inspection Date Ll 1 <br />Time In Time Out <br />Business Rep TitleO <br />AM % O AM <br />O 1 a PM <br />_ <br />® PM <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type - <br />(Fill all that apply) <br />Tire Count (Whole/PTE) 11 <br />L <br />® Active <br />Q Closed <br />® Passenger <br />Q Altered <br />® Generator <br />Q Outdoor <br />O <br />GPS Latitude <br />Q Hauler <br />0 Indoor <br />Q Inactive <br />Q Truck <br />O <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End Use <br />Q Container <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 Reel- ka2l, �L'✓1�( <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />— .. --------------..__—...._. - - ------ <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />- <br />V <br />V <br />-- <br />A <br />-- <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m M / m <br />Q <br />Q <br />14 CCR § 18459.1 -Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />— <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CIWMB Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities— <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />in compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments <br />Inspection Form Included: Q <br />W�w_' <br />Comments Included: *I-- __ -- ---- - - --- - <br />Busme s Rep' ignature Phone Number s Phone Number <br />- <br />INSTRUCTIONS ON BACK Correct: Incorrect: I„ 'k, A iii �..,..._ 1 2 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: VE <br />rA <br />