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■ Waste Tire Sui „ey & Inspection Repori. Inspection Report Number <br /> CIWMB81California <br /> '(New04/04) Survey Form - Pa e 1 1141031 <br /> California Integrated Waste Management Board J <br /> Part A- Survey ___ BLUE OR BLACK INK PEN I <br /> Business Profile :Inspection Details <br /> - <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: ` 5 1 d g 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local e - t If Referral,choose referral type(Fill one) <br /> Identifier: SUS J0CLGU11n Cdu� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical <br /> sical Address <br /> \ Inspection Date <br /> `� ��br <br /> Time In Time Out <br /> Business Rep r Title � O 0 AM O�PM <br /> PM M <br /> `7 <br /> ------ - - -- - -- - - - — — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f � ?j <br /> ® Active Q Passenger Is Generator O Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler e Indoor <br /> 0 Q Inactive • Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> - - - - -- - - - - J ---- -- — -- - --— - <br /> Business Type Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair •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 . <br /> A HAULING AND MANIFEST REQUIREMENTS 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 I Date <br /> M / m / m <br /> 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 • 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 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 4 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> CommentsL�l� <br /> -kC 'A oto i� V.1 u S o orT�r�' - ------ -- - - <br /> Inspection Form Included: Q i %&31T78i <br /> Comments Included: 0, <br /> n re Phone Number Inspe is Signatu a one Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Gf: �/,I X r P L . 1 1 2131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C tY <br />