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Waste Tire S%.. vey & Inspection Repo. _ Inspection Report Number ■ <br /> A <br /> State of <br /> 81California <br /> 04104) I 1 - 1144042 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> P--t A-Survey- BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> f,ID- _ Inspection Type (Fill one) <br /> Site Suffix: , Q # Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v� � lY�, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Businesnns or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> T� cNn L�1 ill" E t <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> � 0 <br /> �� ��\-\, <br /> O PM PM <br /> I�.:►C�✓� <br /> Os '-- -- - - —.-. . - — — - <br /> -- -- —. -- -- — p StatusTire Type Business Role Storage Type <br /> (Fill oneonly) <br /> y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger ®1 Generator Q Outdoor <br /> O A Closed Q Altered ' <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> jV A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q - Q 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 /> F[I / 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 0 -- - - - <br /> 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 O 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 /> ec <br /> �pection Form Included: Q <br /> Comments Included: --���� W FGBusiness Rep's Signature_ Phone Number Ihsre _ Phone Number <br /> INSTRUCTIONS O <br /> - - -- <br /> I � 62081 <br /> N BACK ' Correct:* Incorrect. �' � V! +� �' <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />