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1, <br /> ® Waste Tire Sui vey & Inspection Repok Inspection Report Number ■ <br /> CIWMB California1(New 04/04) Survey Form - Page 1 Il - 1144046 <br /> California Integrated Waste Management Board <br /> A-SurveyBLUE OR BLACK INK PEN <br /> iness Profile Inspection Details - <br /> TPID- 4q ) Inspection Type (Fill one) <br /> Site Suffix: 5 8 —{ L` Q I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �`IoC ��R /O�l If Referral,choose referral type(Fill one) <br /> Identifier: � � [ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ` A <br /> Inspection Date l 41\� 1 <br /> ��``� CA rv,Qk t , Time In Time Out <br /> Business Rep Title 4)AM ) "'] ® AM <br /> C) <br /> i ' U O PM { f c2 ` 0 PM <br /> ( v� Rik : - -� -- -ol -- - - <br /> - --- - - ----- --- - ---- -- ---- - Operational Statusl 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 Q Generator Q Outdoor <br /> Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> siness 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 /> V Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - - - - <br /> -- - --- -._ ........ <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q QQ Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 1.4 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 1 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 /> Inspection Form Included: Q. �apg) (003�o1oa`i <br /> Comments Included: ® — <br /> Business Rep's Signatu Phone Number I r' Signature - Phone Number <br /> �y - - <br /> INSTRUCTIONS ON BACK Correct Incorrect: 62os <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />