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■ Waste Tire Su*y & inspection ReportIMInspection Report Number <br /> state of CaliforniaCIWMB 04/04) <br /> - <br /> California Int grat d,81 WaseeManagementBoard Survey Form - mage 1 I 1 1141220 <br /> Part A. Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _L I L , - Inspection Type (Fill one) h <br /> Site Suffix 9 ? j <br /> L L , •-_� Routine Re-inspection <br /> Q Referral Q Observation <br /> Identifier: t �(.�I l <br /> Local 1 If Referral,choose referral type(Fill one) <br /> �`�' t ���C �� ' °1 _ I <br /> Q CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> t L �CJ1 l <br /> _......_/6.`7 _ <br /> 0. <br /> S .treet r <br /> Inspection Date i l I C <br /> ;;,,ate / it ,, Time In Time Out <br /> ........ <br /> Business Rep Title <br /> D AM O AM <br /> PM <br /> O PM <br /> _ <br /> - Operational Status Tire <br /> P Type ) Business Role Storage Type <br /> The Count{WhoIeIPTE� j <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (T=ill all that apply) <br /> (it Active C Passenger O Generator 0 Outdoor <br /> O 0 Closed Altered <br /> GPS Latitude O Hauler O Indoor <br /> ......... <br /> O O Inactive 0 Truck <br /> Longitude - 0 End-Use 0 Container <br /> Q Planned O 0'1-f� <br /> # 11 that apply} <br /> New Tire Dealer 0 Auto Repair Trucking Fleet <br /> P g O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder O 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 /> 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date � / / 1:11 <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB 1:11 LO <br /> Q Q 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 /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 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 _ I <br /> jC <br /> l i0 ` i - - <br /> Inspection f=orm Included: O <br /> Comments Included: <br /> - Business Rep's :Signature Phone Numow Insz�ec ri>`s igrrrrtuse P� `. <br /> .62081 <br /> ® INSTRUCTIONS ON BACK Correct:® Incorrect: X ,X ,a I g I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />