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Waste Tire Sur ,,;y & Inspection Report -.-apection Report Number <br /> CIWMB California 04/04) I 1 - 1143490 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey_.,_-___- <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 39 <br /> 1 -- Inspection Type (Fill one) <br /> Site Suffix: 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 'D <br /> \ �,, If Referral,choose referral type(Fill one) <br /> Identifier: �J!✓'L� v � �r 1 � �(� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 ( 14 � dna <br /> Inspection Date � � C) GI <br /> L CA q5,�qo <br /> Time In Time Out <br /> Business Rep Title iO AM O AM <br /> ' <br /> l ,2 3 m PM U O PM <br /> -- ---- --- - "� --- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whol <br /> �� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> TE <br /> 0 Active Passenger ® Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude — 0 Planned 0 OTR ® End-Use e 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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ' A I HAULING AND MANIFEST REQUIREMENTS j• 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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date IT-7Ft !/ / Mlo <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 EXT) <br /> 0 0 - _ - --- <br /> 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/CIWMB Enforcement <br /> 00 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 /> Ins ectionForm Included: <br /> Comments Included: ®, - - <br /> 71 <br /> Bus ness Rep's Signature Phone Number I41 <br /> e S' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect � l �1 62081 <br /> ■ _- - - - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />