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Inspection Report NumberWaste Tire Sub§y & Inspection Reporto <br /> State of California <br /> CIWIVIB 04/04 <br /> � i/� }0^; � ■ <br /> California Integrated f W81 as eeManagement Board Survey Form - Page 1 10 10 8 3 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID-} f Inspection Type (Fill one)Site Suffix: �/ I (0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> -- <br /> Business or Facility Name Inspected By Inspector <br /> --. <br /> Physical-. <br /> Address <br /> Street <br /> / Inspection Date <br /> I tv �� �1State ZlP Code I Time In Time Out <br /> Business Re0 AMp Title EL I— FOAM O PM �� .. O PM <br /> Op t oare ii nal Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)'. <br /> Tire Count(Whole/PTE) T <br /> y ,u <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> LatitudeETJ <br /> GPS 0 Hauler 0 Indoor <br /> _ a0 0 Inactive 0 Truck <br /> LongitudePlanned— OTR 0 End-Use 0 Container <br /> G=J <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / ITI / M <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0, <br /> Comments Included: 0 Business Rep _ - _ <br /> ' <br /> 's Signature Phone Number Inspectors Signature Phone Number <br /> _ <br /> INSTRUCTIONS ON BACK Correct:O Incorrect: X A�, I. °,' •y ', = �� 1 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />