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09112040406 <br /> Waste Tire Survey & Inspection Report Inspection Report NumberStat ■ <br /> Ci1W Californiao, Survey Form - Page 1 I 1 - 1088078 <br /> CIWMB 18t(New OModl,. Y �7 <br /> Calirom1.Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ C Inspection Type (Fill one) <br /> Site Suffix: a 4 d JIII [Ell ®Routine Q Re-inspection Q Referral Q Observation <br /> .Local ) If Referral,choose referral type(Fill one) <br /> Identifier: �nn/iw(1 C0�( u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "`1 Inspected By Inspector <br /> Physical Address <br /> �i_•-Y►l.Dl3.C.� �f1J•� i <br /> Street D V, 1 to, I'—'--' <br /> Inspection Date <br /> CcityO Stato [l ocs Time In Time Out <br /> Business Rep Title O AM y�` I Q AM <br /> r „" I PM V o ®PM <br /> �10Se Pa�- o S�iaf A5` •t llf4 `—_ - - — <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 /> V Q Active •Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> -- - Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notiee Of violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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(or NOV or FXfJ <br /> Q Q 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 In Compliance - No Violations <br /> Q Q Other: § <br /> CommentsA', <br /> - — —W—�W— <br /> �o—h -iio_R <br /> Inspection Form Included: <br /> Comments Included:Q u71 J l) V - �Q-1-,R <br /> Business R 's atur Phone Number Inspe rs Signature hone Number <br /> . INSTRUCTIONS ON BACK C r t• ncorrect: EXAMPLE 1 2 3 62061 <br /> White Copy CIW Yellow Copy.Operator Pink Copy:LEP. ® ■ <br />