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M _ Waste Tire S"rvey & Inspection Rept. ,L Inspection Report Number ■ <br /> CIZB California 04104) Survey Form - Page 1 I 1 - 1140801 <br /> California Integrated Waste Management Board ! �+ <br /> -- BLUE OR BLACK INK PEN <br /> A- Survey-- <br /> ness Profile Inspection Details - <br /> TPID- V Inspection Type (Fill one) <br /> Site Suffix: 35 Q ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �^ , If Referral,choose referral type(Fill one) <br /> Identifier: t � �X-K�l � �` L Cin- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busi��ne__ss or Facility Name Inspected By Inspector <br /> Coun ILI <br /> C _ ,n <br /> Physical Address <br /> Inspection Date ` \ / a / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> k 1 ® PM • PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> GPS Latitude O • Closed Q Altered <br /> N/A Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I <br /> R,isiness Type (Fill all that apply) <br /> yew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> U Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other �� �L-��� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility (ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 <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,,EXT) <br /> Q 014 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -_ - - - - <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 <br /> ICU <br /> Inspection Form Included: Q <br /> Comments Included: e -- �� 7 <br /> _Business Rep's Signature I Phone Number Insp I afure Phone Number <br /> - - \---I J 31 <br /> - _.. j12 <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />