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t <br /> ® Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> •�: <br /> State of California <br /> CWMB grated 1(New04104) Survey Form - Page 1 I 1 - 1140570 <br /> California Integrated Waste Management Board <br /> Part_A- Survey BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> y - Q Inspection Type (Fill one) <br /> site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> �Cy) �GY.th..C,<<t,-�, Ce Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> N. X19 ! - <br /> Inspection Date / <br /> /� 9s1zv <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> 03 ® PM 0 U ® PM <br /> Operational Status i Tire Type I Business Role j Storage Type <br /> Tire Count(Whole/PTE) f f (Fill one only) (Fill all that apply) (Fill all that apply) i (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q-Indoor- <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 /> Ised Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler ® Agriculture Q Shredder Q 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 /> ---- I 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 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR 18459.3-Retention of Comprehensive Trip Logs for 3 Years <br /> i <br /> Q Q 14 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> jn + ornihe No Viofatio�s <br /> O O Other: § = <br /> Comments <br /> rn_c3�n�v — <br /> X, <br /> coon Form Included: Q' c <br /> Comments Included: c ��y l 1/ - -- - ----- - - - <br /> ® - <br /> Busi <br /> PR ignature Phone Number �hspect Signature Phone Number <br /> r � 62081 <br /> INSTRUCTIONS ON BACK Corlrgt, Incprirect t � �; E X 2 <br /> __ , .... <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:LEA <br />