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Waste Tire Si,_ -y & Inspection Repo4 Inspection Report Number <br /> •'. State B California 11 .1- 088308 <br /> +ia CIWM grated 1(New Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- rr EboT <br /> Inspection Type (Fill one)Site Suffix: lJ t ' Q Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ; C.t Z (�(�:(,ti f�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ Inspected By Inspector <br /> Physical Address <br /> _117 f,_ 6.,-(1 A I ,1 IC VGI 1 L)t <br /> Street � m <br /> Inspection Date <br /> State ZIP ode <br /> l Time In _ Time Out <br /> Business Rep 4r Title LO AM Q AM <br /> 1C3tc, 1 �• �!/ O PM r O PM <br /> -- - <br /> 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 Q Passenger C Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • Q Hauler Q Indoor <br /> 0 1 Q Inactive Q Truck <br /> Longitude - I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 <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 <br /> 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 I 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q j <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �r 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1p a. ",�I�P i 123 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />