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r Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ■ HA <br /> _ <br /> State of California 11 - 1143988 <br /> S2S8 CIwMB181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A-Survey - - - - <br /> ,iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i J G� I _ Routine Q Re-inspection Q Referral Q Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: ��1n �� '1�17-1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business <br /> �or Facility Name Inspected By Inspector <br /> ^ <br /> Physical Address — 1`I ?zYJ � ! t rG�l <br /> _ Inspection Date <br /> Time In Time Out 40 <br /> Business Rep Title AM <br /> ® AM ) 2 <br /> 1 (� O PM ( `J O PM <br /> -- — - —- Operational Status Tire Type Business Role Storage Type <br /> �y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) , C//JI <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered A11 A N/A <br /> PS Latitude <br /> � YlA Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End Use Q Container <br /> --isiness 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 49 Other (CJI f�� ►l� ' ' <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I 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 0 Other: <br /> Comments � tnq <br /> V <br /> A ''t� �-� flit i �S►�L / r»r�:� <br /> Inspection Form Included: Q p67 <br /> Comments Included: Q' — -_ -- <br /> Business Rep's Signature Phone Number ctor' gnature _ Phone Nurnber,- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:. Incorrect: X �% �/ J X A M P L f 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> ■ <br />