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� Inspection Re o — Inspection Report Number: . Waste Tire Survey & p p � <br /> `•"' CIWMBCalifornia <br /> 11(New04/04) SurveyForm - Page 1 11 1140922 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- // Inspection Type (Fill one) <br /> Site Suffix: a �Q ` 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: Sou)70��f1 G-tk() _� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busine or Facility Name Inspected By Inspector <br /> ep e) 5 _ I <br /> Physical Address l Dip <br /> - - -- <br /> Lodi <br /> Inspection Date I J <br /> Lodi ( l gsawo Time In Time Out 111 <br /> Business Rep Title i � Q O AM : AM <br /> O <br /> — ` I 0 PM �dJ PM <br /> Operational StatusTire Type Business Role <br /> Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> (Fill all that apply) <br /> Tire Count(Whole/PTE) f <br /> S Active ® Passenger Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive I Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 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 Q Notice Of Violation Q Extension <br /> Q j 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 la 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 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!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 S In Compliance - No Violations <br /> Q Q Other: § 11 -- <br /> Comments <br /> Inspection Form Included: Q11) <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspe5py: <br /> Phone Number <br /> - - - — _ — -- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �; - t oI z 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink <br />