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Waste Tire Lar „ay & Inspection Rep*! Inspection Report Number ■ <br />1° CIWMB 81California <br />(New 04/04) Survey Form - Page 1 Il 1143642 <br />California Integrated Waste Management Board <br />'art__A --Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - --7 Inspection Type (Fill one) <br />Site Suffix: ` I �� J _ _ ' ® Routine Q Re -inspection Q Referral Q Observation <br />Local (� 4 v If Referral, choose referral type (Fill one) <br />Identifier: -� ~� ,w,��� t OUT� O CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name ( Inspected By Inspector <br />Physical A dress� <br />o2D <br />fi Inspection Date <br />[�'lL GJ f <br />( C� <br />Time In Time Out <br />Business Rep Title AM O AM <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />IJt ,ne r z. L <br />_-�p ---- <br />N <br />l —1 <br />O PM <br />Tire Type <br />Z_ 1 <br />C' PM <br />Storage Type <br />Operational Status <br />Business Role <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />4@ Passenger <br />® Generator <br />® Outdoor <br />Q Closed <br />Q Altered <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />Q <br />I Q Hauler <br />Indoor <br />Q Inactive <br />Q Truck <br />O <br />0 <br />Q Planned <br />Q OTR <br />O End -Use <br />Q Container <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Used <br />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 - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />O <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />O <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />0 <br />Other: § <br />Q Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date �m/m <br />(Required for NOV or EXT) <br />Q Referred /CIWMB Enforcement <br />e In Compliance - No Violations <br />3 Fly <br />nspection Form Included: Q , ,� .,C cam/ <br />Comments Included: Q _- - - l t�+f - — - - ---- - <br />usiness Rep's Ign Phone Number Ins or'srS' n ure Phone Number <br />INSTRUCTIONS ON BACK _Correct. Incorrect: \-Z <br />62081 <br />d 11al <br />■ White Copy: CIWMB Yellow Copy: Operator Pink py: L ® ■ <br />