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Waste Tire Su_ ey & Inspection Repor,, Inspection Report Number ■ <br /> State CIWMB California T 1 - 114 3 8 4 4 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' 2 _ -^� Inspection Type (Fill one) <br /> Site Suffix: 5 J 5 ' C7 l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: Scm �C,��/IM I,C-> Y! �./ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address <br /> �. <br /> Inspection Date � � � 5 � l <br /> �.��C,.h,rcYl co'_ 515" <br /> Time In Time Out <br /> Business Rep Title O AM0 AM <br /> J r PM 4 PM <br /> — Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) V <br /> r r f Active 0 Passenger 0 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive ® Truck <br /> Longitude – 0 Planned 0 OTR 0 End Use 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 Other <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 <br /> M / m / m <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 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> CommentsG lI��ZSVl <br /> 07- <br /> [Inspection <br /> Inspection Form Included: 0 t� � – <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number I s ctor gnature _ Phone Number <br /> _ _ -- �-�.�, 62081 <br /> INSTRUCTIONS ON BACK Correct:o Incorrect: tiM~ P 112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink op ® ■ <br />