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Waste Tire Su. - ey & Inspection Report Inspection Report Number <br /> State CIWMB California I 1 - 114 3 7 8 4 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� Vx� l7 � - O Inspection Type (Fill one) <br /> Site Suffix: /y ( ® Routine Q Re-inspection Q Referral 0 Observation <br /> Localr 1n If Referral,choose referral type(Fill one) <br /> Identifier: ' l ;)�(�� C— tit Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical ddres� - <br /> 1 <br /> Inspection Date 1 O <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' ® PM U1 0 401 PM <br /> - - — Operational Status, Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ° I ' 3 G L{ ® Active # Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude O Hauler ® Indoor <br /> � Q Inactive � ® Truck <br /> Longitude - Q Planned ® OTR I Is End-Use • Container <br /> Business Type (Fill all that apply) <br /> a New Tire Dealer Q Auto Repair Q Trucking Fleet O Government ® Retreader O Dismantler O 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAU LIN G AND MANIFEST REQUIREMENTS l <br /> j Q Notice Of Violation Q Extension <br /> o O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 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 <br /> i In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form Included: * ^ <br /> aas- 9�3-5�9S"r <br /> Comments Included: 111111 --- - - - <br /> B ess94 <br /> JRSignature Phone Number I to Si at Phone Number <br /> INSTRUCTIONS ON BACK -Correct --Incorrect: A ! � 1112 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />