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® = Waste Tire Survey & Inspection Report Inspection Report Number <br /> a4 <br /> State of California I 1 - 11408 5 0 <br /> CIWMB <br /> grated astew04tt14) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> pace$A- Survey BLUE OR BLACK INK PEN <br /> siness Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site Suffix: ' (p 3 L ! 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: yti (""— J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �— <br /> Inspected.By Inspector <br /> -7_c'Yra /L( «'-r <br /> Physical Addr — <br /> I C'rlcvri T'EC <br /> 1 Q Inspection Date <br /> Time In Time Out <br /> Business Rep Title / ®AM <br /> f O QPM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r,( (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 /> 0 ® Closed Q Altered <br /> GPS Latitude Q Hauler i Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR 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 /> LoService Station Q Hauler Q 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 /> 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 m / m / m <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 /> 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 /> 0 0 Other: § <br /> Comments <br /> 'fi-�-- <br /> - LCcv�-� wl wiA C <br /> action Form /�nc <br /> ncluded: Q ��N �— "✓ <br /> Comments luded: ® �'er(_C12S.)�g� ry`��o3 6 CZ�xr) t,F6�-o z3 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X _r A M P I L 1E 11213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />