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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMBI1(New 04/04) Survey Form Page 1 I1 - 1140792 <br /> California Integrated Waste Management Board Y - J <br /> Part-A-Survey _ _ _- - BLUE OR BLACK IN PEN <br /> isiness Profile Inspection Details <br /> ,PID- I I O Q� n C _ O Inspection Type (Fill one) <br /> Site Suffix: �p b `� J * Routine Q Re-inspection Q Referral Q Observation <br /> Local e� 1 If Referral,choose referral type(Fill one) <br /> Identifier: SCLO J OP,t,�U.l n co4w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name inspected By Inspector <br /> Physical Address <br /> CA, OG1 -O^ C A �r-a0k Inspection Date <br /> 1t„` -J Time In Time Out <br /> Business Rep Title O AM O AM <br /> ®PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> n( <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �J <br /> f Q Active Q Passenger Q Generator Q Outdoor <br /> D 0 Closed Q Alte ed I <br /> GPS Latitude i'Q t,V Q Hauler Q Indoor <br /> O Q Inactive Q TrucV0 <br /> Longitude - Q Planned Q OTR o End-Use j 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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service 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 i 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 o 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 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q o 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> o 1 o 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q o 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q o 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 n1�liGU1 w1m cr A, ' llnWeAl"On LrQ ()n7%kS"_�fWL <br /> ection Form Included: I <br /> o <br /> - - - - - aci <br /> Comments Included: <br /> -- - - _ - - - <br /> Business Rep's Signature Phone Number Inspe s Signature hone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect \/' E A I P 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />