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Waste Tire Sua .ey & Inspection Repos Inspection Report Number ■ <br /> CIWMB811for <br /> (New04/04) Survey Form - Pa�uye 1 I 1 - 1143737 <br /> California Integrated Waste Management Board ! J <br /> PartA-_Survey _- - - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f7 I I - O I Inspection Type (Fill one) <br /> Site Suffix: b 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier. S(kn O u,C� C,A — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � Inspected By Inspector <br /> Physical Addressss <br /> MUD W . <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title + /� ® AM AM <br /> c 1 V a 0 PM 0 PM <br /> - --- -- —- - -- -- Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger ®Generator S Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair (9 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 ����� �� �iS�• � � <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A-1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ® Notice Of Violation Q Extension <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 /> MOO / <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 /> 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ® Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § 11 <br /> Comments 4) 1L \ r15 <br /> Inspection Form Included: Q <br /> � Comments Included: I� � �_ Inspet 's <br /> �' usi ess Rep's Signature Phone Number cSignature Phone Number <br /> INSTRUCTIONS ON BACK j Correct:* Incorrect: X '� ,�/ E X A MIP' 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />