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EEI <br /> Waste Tire Su. -y & Inspection Report Inspection Report Number <br /> Ef State of California <br /> CIWMB1811(New04104) Survey Form - Page 1 Il - 1140765 <br /> California Integrated Waste Management Board <br /> Part A- Survey- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ r Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Gt v 1 ��t�-c r`v�.� Q CHP Q CIWMB ' Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 3 9 <br /> I <br /> Inspection Date / U / 1 O <br /> Li nc.(.�.w CA S,Z 3(G <br /> Time In Time Out <br /> Business Rep Title ® AM 0 AM <br /> I O PM / 'Z © ®PM <br /> �� O tr/rt�J1 Operational Status Tire Type Business Role Storage Type <br /> Tire Count (W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) -- - -- --- - - /�� <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j_ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- -- — Q Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 I 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 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 Q Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> j <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments r� �� �� sl�� 4 jl�i"� <br /> f��t�h nc>�e+f��� �s' <br /> --AACf r -<2 olcr�= <br /> Inspection Form Included: Q <br /> Comments Included: ® Zu4 for 04,Z <br /> Business Rep's Signature Phone Number Inspector's.Signatur . . Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X TX 1 62081 <br /> - - --=— <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy. <br />