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Waste Tire ,di .ay & Inspection Rep..,-t Inspection Report Number ■ <br /> CIWMB8111fornia <br /> (New04/04) Survey Form - Page 1 I1 - 1140838 <br /> California Integrated Waste Management Board J <br /> t A-- Survey <br /> BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> t PID- Inspection Type (Fill one) <br /> Site Suffix: a /Q ` Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: say` V}� Cu�►�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ,,n�cc(C 'L/)\'-\ <br /> ki• te' anc� f�i�7C�t �ca 3 <br /> Physical Add ss n <br /> t+- nU . <br /> Inspection Date <br /> L. e VA CA q,5 oz 6 l `J <br /> Time In Time Out <br /> Business Rep Title 5 0 0 AM �-y &AM <br /> ® ib PM I l/ 0 PM <br /> --- -- — ----- -- ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Generator Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> .� 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 �CL <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V F A i 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. i Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / <br /> FF / M <br /> Q 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 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments <br /> ���_�►���f_� --_mac- - - - - - <br /> zipection Form Included: Q' <br /> Comments Included: - <br /> _ :31-q-Asr' <br /> �1 - 6 - '?6 7 <br /> F __ ___ __ , iness Rep's Signatur Phone Numberure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />