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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State B California Survey Form - Page 1 I 1 - 1140956 <br /> CIWMB 187(New nage) Y ry <br /> California Integrated Waste Management Board y <br /> t A- Survey - - _ - - BLUE OR BLACK INK PEN <br /> iiness Profile Inspection Details <br /> ,JID- 0 ( Inspection Type (Fill one) <br /> Site Suffix: <br /> 0Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCt(� J 1�1�1 Covin Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical ddres <br /> --- <br /> �/� CA Inspection Date l l / 5 ( O <br /> Time In Time Out <br /> Business Rep Title (� O AM C) O AM <br /> 3 ' v 5 QPM 0P <br /> --- - — - <br /> Operational Status Tire <br /> - - p 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O • Closed Q Alterec# n N <br /> GPS Latitude 'n "1 �� <br /> O Q Inactive Q Truck Q Hauler Q Indoo <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Rusiness 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 /> Lo Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> _- -- -- -----------...----- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 /> O0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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/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 Q Other: § <br /> Comments_!L,�-�� <br /> ---- ------ — <br /> U i olA - <br /> (ji )C�r <br /> . <br /> I. ,.action Form Included: <br /> QQ <br /> Comments Included: <br /> Business Rep's Signature Phone Number n�a,'sature- _ Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: t V' , M p Il t 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />