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Waste Tire AW & Inspection Repspection Report Number ■ <br /> `t9 CWMBI 1'fornia <br /> (New04/04) Survey Form - Paae 1 I 1 - 1143521 <br /> California Integrated Waste Management Board J g <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 56 ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� �Ci.Vl / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ ( Inspected By Inspector <br /> Physical Address I �� <br /> Inspection Date <br /> AC(-M p o f�r�� Time In Time Out <br /> Business Rep Title �7 O AM 0 AM <br /> ` c7� CJ tnj o PM �� ® 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 /> ® Active Q Passenger ® Generator ®Outdoor <br /> O Q Closed �Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive O Truck <br /> Longitude — ®OTR Q End Use Q Container <br /> Q Planned <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 IS Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> rV r A l 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 <br /> 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 /> 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 1 Q Other: § <br /> Comments //�► <br /> Inspection Form Included: Q <br /> Comments Included: etrenatre <br /> u ness Rep's Signature Phone Number Ins Phone Number <br /> INSTRUCTIONSO B CK (Correct:) Incorrect �/> > X , €� i 62081 <br /> - — <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />