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.� Waste Tire S� & Inspection Re <br /> 000nspection Report Number <br /> CIB California <br /> 04/04) I 1 - 114 3 6 81 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` r 6 a I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local l , If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical AddressCA <br /> l Inspection Date 6 S? <br /> �5a�F3 Time In Time Out v <br /> Business Rep Title 0 AM ^ 0 AM <br /> PML 1 7 0 PM <br /> Operational Status Tire Type Business Role^ Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f e6 0 Active Q Passenger ® Generator lb Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ID Indoor <br /> O 0 Inactive ®Truck <br /> Longitude - Q Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair f Trucking Fleet 0 Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler Q 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 /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / M / m <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)M <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> O O 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 In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> C. <br /> C-0-m-ri1cia—)�S­_4-�jc <br /> Off <br /> Inspection Form Included: 0j <br /> Comments Included: - - 4XM—' <br /> Bushes p's gnat re Pho Number ture Phone Number <br /> INSTRUCTIONS ON BACKCorrect * Incorrect X1Gfi �/i 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />