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� r Waste Tire Sui „ <br /> ey & Inspection Report Inspection Report Number ■ <br /> i" CIWMB California <br /> 81(New 04104) SForm - Pa e 1 I 1 - 1143482 <br /> urvey <br /> California Integrated Waste Management Board J <br /> -- -- BLUE OR BLACK INK PEN <br /> Part A- Survey__ <br /> Business Profile Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: •� V Q Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��� JC:C ��, 6aVk Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 47 <br /> Physical Address L� C1 l O Ll -,►n bLJlc� <br /> l>J Inspection Date <br /> Time In Time Out v <br /> Business Rep Title0 AM 0 AM <br /> `, t Q 0 PM 3 7 ® PM <br /> L�� L 1`G'l.l� LCJ � vtGl)r11� - - - -- - - <br /> ---.-- - ----- ----- -- -- - -- - - --- Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 6 r ®Active Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 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 / m / 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 EXT) <br /> Q O - -- <br /> 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 (8 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § - <br /> Comments <br /> Inspection Form Included: Q'! <br /> Comments Included: ® - --- <br /> i Busin s Rep's Si ture hone Number Inp AL <br /> ture Phone Number62081 <br /> INSTRUCTIONS ON BACK Cor ftvcarrect. �/; ; <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />