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Waste Tire Su- - ay & Inspection Repor�. Inspection Report Number <br /> Its State CIWMB California I 1w 04/04) - 112 7 9 01 <br /> California Integrated'Wast 81 eManagement Board Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspectionType ( -in <br /> Site suffix, 9Routine Re-inspectionOO Referral O <br /> Observation <br /> LocalC^ �� If Referral,choose referral type(Fill one) <br /> Identifier: �,avx c�vl Co L4A,+Z1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> J; �i{-v-c�� I <br /> Physical dress <br /> ICI`IC) s, El ��� �✓ <br /> Inspection Date <br /> CA TDZI l l <br /> Time In Time Out <br /> Business Rep Title 3 O AM O AM <br /> v PM � �� � - 0 PM <br /> —�j - -- - 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 /> ' 0 Active 0 Passenger -0 Generator 0 Outdoor <br /> O e Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 Other F1 <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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i 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 ® In Compliance - No Violations <br /> 1010 1 Other: § <br /> Comments \ LQ j P /o } <br /> C> �t�1.o !2tV <br /> 1'Lr• r � 5 ^� -oee t/ 9 __3 4- t 4`�C_ <br /> # b <br /> Inspection Form Included: 0 (3 <br /> Comments Included: 0 1'�1-- ✓ !`J __._ _ �1-aq <br /> Business Rep's Signature Phone Number --.ns e r 1 ature Phone Number <br /> Correct Incorrect: X <br /> E x A M IX 2 62081 <br /> INSTRUCTIONS ON BACKite <br /> O <br /> ■ Copy:CIWMB Yellow Copy::Operator Pink Cop L ■ <br />