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■ � .. Waste Tire SUS ey & Inspection Reporlblnspection Report Number ■ <br /> State of California > E - i{ <br /> CIWMB 1S1(New 04/04) Survey Form - Page 1 l - . <br /> California Integrated Waste Management Board - <br /> P_art A- Survey _ BLUE OR BLACK INK PEN eX <br /> Busmess'Prof►leif Inspection Details <br /> _, <br /> J Inspection Type Fill one <br /> Site Suffix -1_ ! 2 / Q Routine Q Re-inspection Q Referral Q Observation <br /> 15 ] <br /> Local �� _E — r— If Referral,choose referral type(Fill one) <br /> Identifier: Y T,) .� at _ c r Ft G CJnI <. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name_ Inspected By Inspector <br /> t/ <br /> Physical Address <br /> ' � r <br /> Street !! Inspection Date L' —l�Ei <br /> `� ��> b �/ <br /> Ci ��' ('c)t�) ( f� 1 Time Out <br /> Cif 1 State ZIP Cade Time In <br /> Business Rep Title O AM O AM <br /> ---`�— _ �OPM OPM <br /> -- Operational Status Dire"Type BusinessRoe Storage"Type <br /> (Fill one only) (FIII If that apply) (Fill all that apply) (FII!all that apply), <br /> Q Active Q`Passenger Q Generator Outdoor <br /> Latitude ~ C I Q Closed Q Altered,:, <br /> GPS �Q Q Hauler Q indoor . <br /> �_..IC �'i Q Inactive firuck <br /> Longitude JT <br /> f Q Planned Q,OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> — -- <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O ----- <br /> 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (Din Compliance - No Violations <br /> Q O (Other: § <br /> Comments - <br /> rn r L _ tf.zC.zc <br /> 4 <br /> Inspection Form 'Included <br /> Comments.Included. Q <br /> Business Rep's Signature Phone Number Inspector's Signa turehone Number -; <br /> INSTRUCTIONS ON BACK Correct: Incorrect: x 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />