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® Waste Tire Survey & Inspection Report-..spection Report Number ■ <br />CIWMB81California <br />(New04/04) Survey Form - Page 1 I 1 - 1143551 <br />California Integrated Waste Management Board J J <br />Part A - Survey BLUE OR BLACK INK PEN_ <br />Business Profile Inspection Details <br />TPID -Inspection Type (Fill one) <br />Site Suffix: is Routine Q Re -inspection Q Referral Q Observation <br />LocalI / ��'j_ If Referral, choose referral type (Fill one) <br />Identifier: f\ O Ct U11W Tj� <br />n J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By <br />Dtllco A4o w rc_-(�) a f n 1 <br />Physical Address C <br />- 3) A5 N <br />Business Rep Title <br />f <br />Tire Count (Whole/PTE) <br />- O <br />GPS Latitude <br />O <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair C <br />Inspector <br />Inspection Date <br />V 1 <br />Station Q Hauler Q Agriculture Q Shredder Q Other <br />I V <br />Time In <br />ENFORCEMENT STATUS <br />Time Out <br />Ti <br />A <br />I U <br />Q Notice Of Violation Q Extension <br />fine <br />I <br />/l <br />a V SAM <br />0 PM <br />Q <br />1 <br />O PM <br />Operational Status <br />Tire Type <br />Business Role <br />i Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />• Active <br />® Passenger <br />® Generator <br />® Outdoor <br />Q Closed <br />Q Altered <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />m <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />m <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Trucking Fleet Q Government Q Retreader 4P Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service <br />Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />j <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />m <br />m <br />/ <br />m <br />Q C <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q C <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EX7) <br />i <br />Q Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CIWMB Enforcement <br />Q <br />C <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />n <br />Q <br />n <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Other: § <br />® In Compliance - No Violations <br />Comments U -.11 _ I _ _ I <br />WUS 0 UCc <br />o i 'a1 1 <br />1 ►'11 S <br />r- — <br />Inspection Form Included: <br />r <br />Comments Included: <br />sie R Signature Phone Number Inspe or's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct:* Incorrect: Xi �/1 { A M <br />- -- - - — ® ■ <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy E <br />