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Waste Tire S.-. vey & Inspection Repo. _ Inspection Report Number <br /> .eH71 CIWMB California 04104) I 1 - 114 0 9 41 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Surve - -_ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> -ID- } Inspection Type (Fill one) <br /> Site Suffix: ' u 0 l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC� _ p If Referral,choose referral type(Fill one) <br /> Identifier: J(�1� � 'J w Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> 'U�``� r Inspected By Inspector <br /> � r �c�a )�r� Ci - l l�" by <br /> Physicarddress 3 L <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> QPM � 0 P <br /> - — _ - - -- <br /> - �- <br /> - - - --- - - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Y Q Active 0 Passenger Generator ® Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ - - -- - -- -New Tire Dealer Q Auto Repair Q Trucking Fleet 0-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 /> 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 /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle I <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 j <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q O <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 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 /> In Compliance - No Violations <br /> Q Q Other: § _ <br /> Comments <br /> ,section Form Included: QI <br /> Comments Included: <br /> Business Rep's Signa ure Phone Number r ignature Phone Number <br /> - _.. 62081 <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect ; � Vi 62081 <br /> INSTRUCTIONS 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />