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Waste Tire SfWy & Inspection Repo Inspection Report Number <br /> -gym" Ya _... _....._..__...,.... <br /> State of California <br /> CIWMB1811(New04/04) Survey Form - Page 1 I I 1 - 1141334 <br /> Czlifornia Integrated Waste Management Board .. .._.. _._.___.. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: QRoutine QRe-inspection QReferral QObservation0O _ <br /> Local i ICI � If Referral,choose referral type(Fill one) <br /> Identifier: " (1 ( �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busipess or Facility Name Inspected By Inspector <br /> Physical Address <br /> - - I <br /> ._. i . ._ <br /> ._ a_._.... _.._... _ ...._..._............ B <br /> tf 3_ �..: Inspection Date '.._, _ .._ <br /> atp /R God,, Time In Time Out <br /> Business Rep Title ,- AM i 3 AM <br /> rl �. ` / ^� �.. � <br /> 0 PM 0 PM <br /> � Sod i t r.t1�1.1 >.... {. CIS . <br /> ' j1L - <br /> .. ..... �.__._.! <br /> Operational Status Tire Type ' Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> gl Active Q Passenger Q Generator Q Outdoor <br /> • s� � „ <br /> Latitude ji � D Q Closed Q Altered <br /> GPS t j Q Hauler Q I;idoor <br /> �_ __ ...... Q Inactive Q .Truck <br /> l10 <br /> Longitude I 1 Q End-Use Q Container <br /> Q Planned Q O <br /> -k <br /> Business Type (Fiall teat apply)_ rr <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 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 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M____ m m <br /> IQ 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 /> Q Q 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 Q in Compliance - No Violations <br /> Q 1 <br /> 1 Q Other: §�. <br /> - - _ <br /> (� <br /> Comments <br /> �\ )k ,�i11 <br /> � ` s <br /> 71 <br /> Inspection Form Included: <br /> Comments Included: Q ' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Corr ct ® ncorrect: x � m 'j �. i 2 i <br /> ® White Copy: Yellow Copy:Operator Pink Copy:LEAN ^^) ® ■ <br />