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Waste Tire .,urvey & Inspection Rep ,rt Inspection Report Number ■ <br /> s�= State <br /> r- + California <br /> 11 - 1140653CIWMI3 181New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> A- Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> i eIp_ � � � � � - � � Inspection Type (Fill one) <br /> Site Suffix: l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \\^ If Referral,choose referral type(Fill one) <br /> Identifier: sckyA �C'��( "ll `, �(�t/✓l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> '2,' <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title f 10 AM ® AM <br /> l C� O PM 1 O 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 40 Outdoor <br /> 0 ® Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 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 /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder It Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENRF6RCEMENT 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. 1 Compliance Deadline 1 <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 <br /> 0 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 EX7) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> C'i. LCsY►s Lt7 i E -G - <br /> .._pection Form �nc <br /> ncluded: 0 ` <br /> Comments luded: Gl•t��� — <br /> Business Rep's Signatu Phone Number I cto s'S' ature Phone Number <br /> INSTRUCTIONS ON BACK [ - <br /> Comrect:0 Incorrect X X t ,IVS L 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />