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Waste Tire S%ey & Inspection Repo. Inspection Report Number <br /> � State of CaliforniaCWMB 04/04) <br /> T 1 Q <br /> California Ine grat dt81 WaseeManagement Board Survey Form - Page 1 + + 11 2 7 5 9 7 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 1 ^S 1 "1 1 0 � 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LLocal / If Referral,choose referral type(Fill one) <br /> Identifier: � ! ^ �(�C(( l� (� `_��� (�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> I ' Inspected By Inspector <br /> Physical Address 1 `'' r q0 <br /> t <br /> _. ........._._..._..............._...._.._.._.._........._......_..I <br /> Street <br /> Inspection Date <br /> tate ZIP Code i' Time In Time Out <br /> _.._. _ <br /> Rep Title 0 AM �^� f 0 AM <br /> Business Re <br /> 0 PM ' LJ 0 PM <br /> -) C� .-_._.. _Q.t�.( . .0 _ O erat nal Sta __. �. <br /> ......._ p tus 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> t) 0 Closed 0 Altered <br /> GPS Latitude I i j 0 Hauler 0 indoor <br /> -_,O 0 Inactive 0 Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 M / Fp / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <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/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 <br /> CA <br /> Inspection Form Included: 0 <br /> , <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X _E X A W iP (_ U t 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />