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® Waste Tire Survdy & Inspection Repo. ,L Inspection Report Number ■ <br /> CIWMB 811(N w 04104) I 1 - 1141036 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> - - - --- <br /> Business Profile LInspection Details <br /> — --- l - - - <br /> TPID- � � � y� _ �^ e Inspection Type (Fill one) <br /> Site Suffix: a `7I v 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 ,� If Referral,choose referral type(Fill one) <br /> Identifier: S(�,1� J 1,1 J) C,�vt-nl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> `L Inspected By Inspector <br /> Physical 4ddress <br /> Inspection Date <br /> S������� /�•IN' Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> I -1 5 e PM <br /> pp� 11 m I SPM ` <br /> Fill one only) Tire Type Business Role Storage Type <br /> Operational Status <br /> Tire Count(Whole/PTE) ' 0 t--t ( Y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet - Government 0 Retreader ® 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 Q Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV oi-EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators e In Compliance - No Violations <br /> Q Q Other: § <br /> Comments _Njo - if <br /> Inspeel -117t <br /> ctionmmen s Included: �I �� <br /> usine s ignature Phone Number Inspec r s S nature one Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect IF 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y:LE <br />