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! ' 1 <br /> a <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> LIM State of California <br /> Cgrated 1(New04/04) Survey Form - Page 1 Il - 1140578 <br /> California Integrated Waste Management Board <br /> Part_A- Survey--_ _ _ _ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> Z- Inspection Type (Fill one) <br /> Site Suffix: _-7 � ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t '�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - <br /> Inspected By Inspector <br /> elil r�Y A)>-.(-I- <br /> Physica ress - ` Amiw&t <br /> � <br /> _ Inspection Date t o -C( Z V 5- <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> C? cJ ® PM 2- As PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (O Q <br /> one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Q Generator Q Outdoor <br /> - <br /> Latitude ® Closed Q AlteredI <br /> I GPS OQ Hauler <br /> Q Indoor <br /> O Inactive Q Truck ( � <br /> ( o <br /> Longitude Q Planned Q OTR 1'Y <br /> 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 /> Jsed 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> o;, .„amu � .. <br /> c -- --._..._... . .... - <br /> " �� 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 O 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 O 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 0 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 /> - <br /> action Form Included: Q <br /> LComments Included: — -� Cz�y <br /> Busi s ep's nature Phone Number nspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X � �/ R ; <br /> White Copy CIWMB Yellow Copy:Operator Pink Co y' <br />