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nspection Report Number <br /> Waste Tire Su0by & Inspection Report <br /> CWMB 81(New04/04) Survey Form - Page 1 I1 - 1088359 <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> C Identifier: �'! OCkr� tt'1 `-UU `� `", 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> 40")Ll <br /> ��t�t ;� Cunt�(l!� I _ .1 Physical AddressI To 1 I P)� <br /> srrE5er <br /> Inspection Date <br /> Stare ZIP Code Time In Time Out <br /> Business Rep Title rF III AMAM <br /> 0P '1 �) 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 1 <br /> 0 Closed 0 Altered I <br /> GPS Latitude m . 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — J].�) <br /> Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fi al'that apply)' <br /> 0 New Tire Dealer 0 Auto Repair 4P 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 <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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB 7 <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 i 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments l <br /> C�4V�`� � <br /> Inspection Form Included: <br /> Comments Included: <br /> O,Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X JE X( A MIPILI 3 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />