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Waste Tire Su, _Idy & Inspection Report inspection Report Number ■ <br /> • `°�� CIWMB111fornia(New 04/04) Survey Form - Page 1 I1 - 1143618 <br /> California Integrated Waste Management Board J J <br /> P­rtA- Survey BLUE OR BLACK INK PEN <br /> Iness Profile Inspection Details <br /> Ip_ � � ' � � � � _ � Inspection Type (Fill one) <br /> Site Suffix: I j) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sek 0 Qcul R lrn C,j�Al(� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physic <br /> �alAdd���re s 1►�s � � _ 1 � � ReO c <br /> 1 S C_D�6 <br /> CAgSV.Z Inspection Date LA / U Z <br /> i Time In Time Out <br /> Business Rep Titl\e� O AMO AM <br /> PM � ' � v (ar 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 /> 0 Active ® Passenger ® Generator S Outdoor <br /> O e Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned a OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Jsed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 8 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 1 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 0 Other: § 1 1 ) I <br /> Comments �nt},k 1 t n�,L�(�U/1— _ � " U A -%-I S-��G�LL�_� <br /> C`05e. iCkZXVA a an CAye- -- A% <br /> action Form Included: 0, <br /> (I - <br /> Comments Included:®' ,wr 3Zg `�yL3 v='' " �l J[ !g <br /> Business Rep's Signature Phone Number Inspecs Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X1112 2 62081 <br /> - ---- - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />