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Inspection Report Number <br /> Waste Tire SuGey & Inspection Repor• <br /> ii State of California <br /> CIWIVIB 1(New04/04) Survey Form - Page 1 I 1 - 1141272 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection- T i Inspection Type (Fill one) <br /> Site Suffix: ' p\ � 4�O ( s i i <br /> 0� 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 � If Referral,choose referral type(Fill one) <br /> Identifier: \/� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Ptiysica{ I-Add res\ss._.__._`_.__ I j C� I Q >�U <br /> 6 �1 .....__._ . . .. .. __._...._C7.._��.....b.....__........................__._...._........-....._..._................. <br /> .............._...I <br /> Street <br /> rJ i <br /> Inspection Date V7111 <br /> b <br /> A Q5� L____ __. <br /> AL In Time Out <br /> Slate ZIP Coda <br /> Business Rep Title O AM _ .. i...__ AM <br /> PM I O PM <br /> s . ........N46_0 n _ <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fi ne only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) i <br /> (0-Active / Q Passenger Q Generator Q Outdoor <br /> Latitude <br /> D Closed" Q Altered <br /> i Caps •� � � 1 � t Q Hauler Q Indoor <br /> �_..... r _._.I._ O Q Inactive Q Truck <br /> Longitude - 1 •I I� Q Planned Q OTR Q End-Use Q Container <br /> II III <br /> Business Type (Fill all that apply) <br /> Q 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 HAULING AND MANIFEST REQUIREMENTS <br /> 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 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 for NOV or EXT) <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 O 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 Q in Compliance - No Violations <br /> Q Q Other: § <br /> Comments + _ <br /> , <br /> Inspection Form Included: Q f ~ <br /> Comments Included: Q Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> � <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � LE X i A fit,P, � E 2 1 s 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />