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Waste Tire Swy & Inspection Report Inspection Report Number <br /> 5 State of California ew 04/04) m 1 T 11141279 <br /> 181 <br /> California Integrated Waste Management Board Survey Form <br /> 1 1 age + + <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID _ _ _�� Inspection Type (Fill one) <br /> //�� l) <br /> Site Suffix: �V / �jJ ��— O Routine Q Re-inspection O Referral Q Observation <br /> Local /l If Referral,choose referral type(Fill one) <br /> Identifier: A = = �=j <br /> O(J� uin CV�n� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name , Inspected By Inspector <br /> _ V U vcS <br /> Physical Address t'l <br /> _ — , <br /> SF'- eP <br /> c <br /> Inspection Date <br /> �� <br /> " z` P-L-6-1 <br /> � <br /> Time In Time Out <br /> Stee<c Z,,p <br /> <xfe € <br /> Business Rep Title AM ( O AM <br /> 0 PM <br /> u <br /> �. �. �..y.... ,. <br /> Operational Status 'Tire Type Business Role Storage hype <br /> � (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 'tire Count(Whale/PTE) <br /> '• Q Active 0 Passenger O Generator 0 outcl, <br /> GPS Latitude ° 0 closed 0 Altered <br /> • � _� Q Hauler 0 indoor <br /> Q Inactive 0 Truck <br /> D <br /> Longitude - O Planned 0 OTR 0 End-Use 0 Container <br /> .. <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - - - 0 Notice Of Violation 0-Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q Q 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 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q in Compliance - No Violations <br /> 10 0 Other: § <br /> Comments <br /> Inspection Form Included: <br /> ...Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 3t�- <br /> -7-`- 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X r; �` A M " 12 L3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />