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Waste Tire Sur&y & Inspection Report (Inspection Report Number <br /> State of California <br /> C,WMBgrated 1 teMana a Survey Form - Page 1 - 114115 2 <br /> California Integrated Waste Management Board _..,...,., <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j ! t Inspection Type (Fill one) <br /> Site Suffix: { � i <br /> 1_� mm2 1 1 ( Routine 0 Re inspection 0 Referral 0 Observation <br /> — <br /> Local I0 CfHrPral,choose CIWMBrral type(Fill0 Com ) <br /> Complaint 0 Educational Visit 0 Other <br /> Identifier: 1 <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> 3 <br /> - <br /> Physical Address � i L L <br /> c, / <br /> Inspection Date I f <br /> Sfaft� ��, ; Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> O PM ���. O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE (Fill one only) (Fill all ti-�at apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Pa senger 0 Generator 0 Outdoor <br /> GPS Latitude <br /> C 0 Closed C) Altered <br /> ! 0 Hauler 0 Indoor <br /> .__. . .. O <br /> 0 Inactive 0Truck <br /> Longitude End-Use Container <br /> 9 i 1 0 Planned 0 CTR 0 <br /> Bustne � 1 ' <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 / El <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB Ill <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 I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No.Violations <br /> 0 0 Other: § ....� <br /> Comments <br /> lece <br /> Inspection Form Included: 0 <br /> Comments 9recluded: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone:Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X �,. :,x,1 AM P L�� � j � �I 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> r <br />