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Waste Tire S-. ,ey & Inspection Repo. Inspection Report Number <br /> State of 81(New04/04) Survey Form Page 1 I1 - 1127916 <br /> California Integrated Waste Management Board Y - J <br /> Part A- Survey - _ _-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ® 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Y1 s „h Cn O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (((t Inspected By Inspector <br /> AAA <br /> Physical Address <br /> (�� Inspection Date <br /> C�C_ " _6 <br /> Time In Time Out <br /> Business Rep Title O AM }}�.� Q AM <br /> ®PM I ' tea' ®PM <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 /> � � <br /> ® Active ® Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O 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 /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> ' Q Notice Of Violation 0 Extension <br /> O 0 <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-Registration/Decal in Vehicle <br /> O ! O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O li 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIVVMB 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 /> ;inspection Form Included: Q -� <br /> Comments Included: �-semi —L <br /> si s gnature Phone Number C hsoes nat re Phone Number <br /> INSTRUCTIONS ON BACK I Correct:. Incorrect )'K' , V C - - 213 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C 94 <br /> © ■ <br />