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Waste Tire Sulfey & Inspection ReporA Inspection Report Number <br /> State of California <br /> hs.,� CIWIVIB 1(New04/04) Survey Form - Page 1 I 1 - 11412 4 6 <br /> California Integrated Waste Management Board ..........� ...._ _..,.,.... _... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: - <br /> Routine 0 Re inspection Referral 0 Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: `!'. ,(�(� (� (j�{';�1 € 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address._ — [ ( � <iU J/_ <br /> —s ! <br /> i.ri_._ _' _ _�c� .�........ ...........-.............______ _....__............__._........__ _ <br /> �Eree: ( ♦ I I. <br /> Inspection Date E ` o <br /> .A <br /> t 111 Sian IE t ,d Time In Time Out <br /> _ . <br /> Business Rep Title O AM � O AM <br /> 0 P ' l� 0 P <br /> Operational Status Tire Type ype Business Role Storage Type <br /> Fill one only) (Fill afl that <br /> Tire Count (Whole/PTE) ( y) pp y) (Fill all that apply) (Fill ail that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude s 0 Hauler 0 Indoor <br /> •u............. ' 3 <br /> Inactive l l uc, <br /> k <br /> Longitude _ ' <br /> 9 Planned C <br /> Lon 'r� 0 End-Use 0 container <br /> I I <br /> Business Type !Fill all that apply)' <br /> Yp pp Y)' <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 f or <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 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 /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date 0 <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB LE / FF1 / <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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/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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ! <br /> ,w(1 r n AJC\ ,a ---- <br /> 0 U r,L,,:t — <br /> �j �. t Eta -- tl��' G . r <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signakure Phone Numuer <br /> a _ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X <br /> r� ,�i � �- � i <br /> ® <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> f' <br />