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■ iz Waste Tire Survey & Inspection Repo, c Inspection Report Number <br /> '®Y CIWMB 81California <br /> (New 04/04) Survey Form - Pa e 1 1141039 <br /> California Integrated Waste Management Board J <br /> Part A-Survey -BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: S ( 1 -1 " ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> n �d(,(,�U,)� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N bCAO/S IA e - 1 (0 Ren Es b <br /> Physical Address l C <br /> Inspection Date <br /> LcATime In Time Out <br /> Business Rep Title 3 O 0 PM O V 0 PM <br /> cwS o0 s r�. <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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O • Closed Q Altered A)A tilA <br /> GPS Latitude Nf ; Q Hauler Q Indoor <br /> D Q Inactive Q Truck A I <br /> Longitude - 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 • Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V I 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 /> i <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date M / m / FTI <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 EX7) <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments r __11+ - <br /> ��e, 'C <br /> O °Wtn- <br /> Inspection Form Included: Q <br /> CoLPN- <br /> mments Included: - - - ---- - - 7 _C <br /> Business Rep's Si nature Phone Number �np�_a, aturePhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect Xi Vi � A M P L E 112 3 <br /> ® - --- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />