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■ £ , Waste Tire Su`► _ -;y & Inspection Report Inspection Report Number <br /> CIWMB 81(Nw04104) I 1 - 114 3 5 0 0 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - -- <br /> Business <br /> - j� (� `, Inspection Type (Fill one) <br /> Site Suffix: `' -1 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local70ul <br /> If Referral,choose referral type(Fill one) <br /> SW <br /> Identifier: Ul f) C0� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _--- <br /> Inspected By Inspector <br /> Physics ddress - Rto ES40 <br /> Inspection Date / <br /> Time In Time Out l <br /> Business Rep Title n 1 O AM 0 AM <br /> �( -C O Is PMaA PM� 5 <br /> Fill one only) Fill all that apply) Fill all that apply) Storage Type <br /> Operational Status Tire Type Business Role <br /> Tire Count (Whole/PTE) f 5 ( y) ( pP y) ( pp y) (Fill all that apply) <br /> Active 0 Passenger 0 Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive e Truck <br /> Longitude - 0 Planned e OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair IS 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 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 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 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments � 1 t r I <br /> c \ �k na �s�ra Vie._ Tc—t-nS e , , (���01f%a_ s_L- c <br /> Inspection Form Included: �Comments <br /> Included: —Business Rep' Signature Phone Num er ct s Signature --QhZi* <br /> one Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect. X �+ J E X A P L I f 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />