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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMB 81California <br /> 04/04) S u rVe Form - Pa e 1 I 1 - 1143667 <br /> California Integrated Waste Management Board Y <br /> BLUE OR BLACK INK PEN <br /> 'art A- Survey _ <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Ste Suffix: I L - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � � l ����J1� �v� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> i �, �.1 �� =,-1 C <br /> Physical Address <br /> A-v`c- -- --- - - <br /> ,�-1 <br /> Inspection Date '7 <br /> L.C�J LA (75d o Time In Time Out <br /> Business Rep Title AM &AM <br /> � O PM � � � � � O PM <br /> -- --- ---- - -- -- -- - -- Operational Status Tire Type Business Role Storage Type <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 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned J Q OTR Q End Use— Q Container- <br /> Business Type (Fill all that apply) <br /> 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS li Q Notice 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 Date M / m / m <br /> Q Q 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXTJ <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I 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 /> Comments <br /> Inspection Form Included: <br /> Comments Incl d: <br /> ® Business ep Signature Phone Number In or ignature Phone Num er <br /> ( ` f 62081 <br /> INST C NS ON BA Correct 0 Incorrect: X �i X A M P� � ��I � 1 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />