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& Inspection Re t _.tspection Report Number <br /> Waste Tire �urv�� p p <br /> State fornia <br /> of <br /> 81(New 04/04) I 1 - 114 3 4 91 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Li l - O Routine Q Re-inspection Q Referral Q Observation <br /> Local ^- -,, If Referral,choose referral type(Fill one) <br /> Identifier: ��� CJ�Jt 1 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 9 <br /> g5Inspection Date <br /> L- a�lC j 1 <br /> Time In Time <br /> Out <br /> Business Rep Titl/e� O PM M : O AM <br /> - ---- ---- Operational Status Tire Type BusinePM <br /> ss Role Storage Type <br /> f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f f �/✓� <br /> Is Active ® Passenger ®Generator I® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Planned Q OTR 1 O End-Use O Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O 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 O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA I HAULING AND MANIFEST REQUIREMENTS <br /> II Q Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§ -42956 Re istration/Decal in Vehicle <br /> 9 <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> O O <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> O O 114 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 ! O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> D <br /> Ti <br /> f <br /> t <br /> i <br /> R <br /> 14 CCR§18462-Manifest System Requirements or re Dealers or Waste Tire Generators <br /> ® �In Compliance - No Violations- <br /> O O Other: § __ J <br /> Comments <br /> Inspection Form Included: Q -� <br /> b1 �J S' t <br /> Comments Included: - - <br /> Business Rep's Signature Phone Number pe tor's< ture Phone Number <br /> ---- - - — <br /> INSTRUCTIONS ON BACK <br /> Correct:18 Incorrect. ; , - I j 3 62os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE ® ■ <br />