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=Fs Waste Tire AM & Inspection Reporwpection Report Number <br /> tt _ State of California <br /> CIWMB <br /> ratedW (New04/04) Survey Form - Page 1 I 1 - 1127866 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � a ' Inspection Type (Fill one) <br /> Site Suffix: _ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CN,� i h, Q CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name -� - — -- _ - — <br /> Inspected By Inspector <br /> Physical Address 3 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> I I . o &7- O PM C) 0 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> � � 10 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ®Active ® Passenger ® Generator 0 Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O O Inactive Q Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> e 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 j <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> OO PRC§42956-Registration/Decal in Vehicle <br /> E[] <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O O 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 /> O Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 O Other: § ._---- <br /> Comments <br /> lnJ co; — <br /> Inspection Form Included: O <br /> Comments Included: ® .6`r-062' <br /> — --- - - Business Rep's Sig Phone Number Inspector's Signature Phone Number <br /> -- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 1;, -E X 112131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L ®. <br />