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Waste Tire Sur4y & Inspection Report lonspection Report Number <br /> &3331.+ State of CaliforniaCIWMB 04/04 <br /> ' <br /> California Int grat d,81 Was eeManagement Board Survey Form - Page 1 Ll1 - 1006349 <br /> ry <br /> Part A Surve _ BLUE OR BLACK INK PEN <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix: ` `� V �(' , Q Routine (D)Re-inspection Q Referral Q Observation <br /> Local /___ If Referral,choose referral type(Fill one) <br /> Identifier: ? _44 L{ O CHP Q CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name y <br /> Inspected By Inspector <br /> L <br /> Physical Address <br /> I _ <br /> Inspection Date <br /> ci y State ZIP Code <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> _.. . ... I 1 0 PM I - O PM <br /> Operational Status TI Type Business Role Storage Type <br /> 1, ActFill one <br /> tivoelY) (0 PaFill all <br /> Seng prY) (© Generatoply)i (Fill <br /> OufdooY) <br /> all that rall that ppl ' <br /> hat <br /> Tire Count (Whole/PTE) <br /> 0 Q Closed 0 Altered <br /> GPS Latitude IL� � Q Hauler 0 Indoor <br /> Q Inactive Q Truck <br /> Longitude Q Planned 0 OTR O End-Use 0 Container <br /> 1 Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q 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 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date m <br /> O 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§ 18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ii, In Compliance No Violations <br /> Other: § <br /> Comments <br /> ffiplm <br /> -� <br /> Inspection FormIncluded: Q <br /> �. � <br /> r�mments Included: 0 " _ <br /> Business Rep's Signature Phone'Number inspector s Signature Phone Number <br /> INSTRUCTIONS ON BACK i Correct:I* Incorrect: X V r k', 62081 <br /> �_- ■■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />