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Waste Tire Sul „ey & Inspection Report Inspection Report Number ■ <br /> [1i CIWMB 811(New 04104)fornia 11 - 1143581 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part-A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- L Ll S 5 1 Inspection Type (Fill one) <br /> Site Suffix: �� ( • Routine 0 Re-inspection Q Referral Q Observation <br /> Local /- If Referral,choose referral type(Fill one) <br /> Identifier: ������ C�11�1 1 �-�1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I Inspected By j Inspector <br /> � (� <br /> ca Address <br /> Ph <br /> y [� q5,-2015- Inspection Date 4-1 g <br /> -" Time In Time Out <br /> Business Rep TitleQ �j F� Q AM ®AM <br /> r I J ' ` J 0 PM r� 0 PM <br /> ©�fZe d LrA_\ -- - - — - - -- - - - -- <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 /> f ® Active ® Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR 0 End-Use 1 0 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 /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station ® Hauler 0 Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS__— <br /> _ _ ---------- --- -- <br /> V � A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> i <br /> PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / FF] <br /> 0 Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)C() <br /> O O -- -- . <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O .14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: '� - -- -- <br /> BUSIr1f3S s SI' nature Phone Number In or's i nature Phone Number <br /> X62081 <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: rAi T 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />