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�. <br /> FORM NO.M-105547-CIWMB .,#. , .1,5'4321 <br /> Ca:a <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWIVIB Waste <br /> eManag) Survey Form - Page 1 1 8 - 1 0 7 9 4 9 4 <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: q j - U ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ���yt cab-c-� ►^� l;yru.vl'a- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - Inspector <br /> - <br /> e „V, �„(Sv,VCtt'—e-'.4 Inspected By <br /> Physical Address <br /> Inspection Date <br /> �A q S�v � <br /> Time In Time Out <br /> Business Rep Title AM ® AM <br /> O PM O 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 Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 ® Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use 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 1..� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEME_NTSTATUS <br /> HAULING AND MANIFEST REQUIREMENTS <br /> A PRC 42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extensiorr <br /> O § 9 - p <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q IQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> - ----------------"----------- ------------ ---...- <br /> Q 0 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 tQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations 1 <br /> Q Q Other: § <br /> - - <br /> Comments / <br /> 4e 4A Vr— <br /> Inspection Form Included: Q <br /> Comments Included: Q � <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />