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Waste Tire Sur „ey & Inspection Report Inspection Report Number ■ <br /> State of CaliforniaCIWMB 181 T 1 <br /> ew 04104) <br /> California Integrated d Wastle Management Board Survey Form - Page 1 i i 1143624 <br /> t <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � Q � � - Q � Inspection Type (Fill one) <br /> Site Suffix: -1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local "—( r(, If Referral,choose referral type(Fill one) <br /> Identifier: QkJ Q u,1 n &kk 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address \ 1� E S j&O <br /> --- <br /> c.��n Inspection Date <br /> H Time In Time Out <br /> Business Rep Title (D CAM 0 •AM <br /> bulk,, QO J UnJ � O PM � �/ O PM <br /> - - --- --- - - - `5- Operational Status Tire 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 /> Active Passenger Generator Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler I* Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) d � � _ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder OtherJ�� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i <br /> HAULING AND MANIFEST REQUIREMENTS <br /> 0 i 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle _P <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O - --- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § —.- <br /> Comments 1 1 <br /> � ,0Is(cAk0(1\ DOA03T nANN, _kc � lo <br /> Inspection Form Included: 0 - <br /> Comments Included:® - - <br /> -- y- -7oyi (a j1`7)U-3� $_ <br /> Bu mess Rep's ature Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK !Correct:0 Incorrect X I- , E A E I ' ? 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y:L A ® ■ <br />