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_ Waste Tire Su. iey & Inspection Report inspection Report Number ■ <br /> CIWMB181fornia <br /> (New 04/04) Page 1 Il 1143477 <br /> California Integrated Waste Management Board Survey Form - <br /> Part A-_Survey_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � [ � O � � � - O I Inspection Type (Fill one) <br /> Site Suffix: 7 • Routine Q Re-inspection 0 Referral Q Observation <br /> Localr- 1 If Referral,choose referral type(Fill one) <br /> Identifier: 5(�(� J Qag stn cou'`I' 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M 4 J &ae.fV i Ce- q <br /> Physical Address �Q(� �S� O <br /> 1\ID\L S, <br /> [ (� A Inspection Date I <br /> �' " `t Time In Time Out <br /> Business Rep Title O AM O AM <br /> O QPM O 0P <br /> - -'idi to O�Junt'r Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> G (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J <br /> •Active Q Passenger 0 Generator Q Outdoor <br /> 0 O Closed 0 Altered <br /> GPS Latitude O Hauler O Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - O Planned Q OTR O End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 Q Agriculture Q Shredder ® Other <br /> ... <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> O O 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-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O ® 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> rO 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 1 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> CommwAs Form <br /> Form Included: O <br /> G`�\ <br /> �I <br /> ( U R <br /> Inspection Comments Included: nol �"S - <br /> Busm s e ig ature Phone Number Inspor's SignatureA Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect T 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />