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CE <br /> Waste Tire Suay & Inspection Report'Inspection Report Number <br /> EEEl-_ State of California <br /> CIWMB1811(New04104) Survey Form - Page 1 1 $ 1 0 7 9 3 4 6 <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /� rnetion Type (Fill one) <br /> Site Suffix3� J-Z <br /> v / utine ® Re-inspection Q Referral Q Observation <br /> Local rral,choose referral type(Fill one) <br /> Identifier: V��CC.LG — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �L / � ��-' o��u I- '� <br /> Physical Address - ` Q <br /> J Inspection Date 0 6 <br /> �""-V""' (/� Time In l/ Time Out <br /> Business Rep Title O AM O AM <br /> 0 Z ®,PM Q ® PM <br /> - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire COun (bhe/PTE) ' `Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger ® Generator (a Outdoor <br /> O Q Closed ®Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR ® End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0-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 ® Other (x <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility iENFORCEMENTSTATUS <br /> V A. HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> 0 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 FA <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date16� /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 EXT) <br /> Q Q ------- - --- - - - ---- ... - - <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 Referred/CIWMB Enforcement <br /> 0 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 /> Other: § - <br /> - -- - - <br /> Comments r\.A- <br /> V <br /> Inspection Form Included: <br /> Comments Included: ® - - � tIJ�G� - - R ���=� <br /> sin s Re 's ig ature Phone Number I pector's Signature Phoneuuhber <br /> f qs �r <br /> INSTRUCTIONS ON BACKo p 62081 <br /> _, _ ., <br /> Whiteopy:CIW Yellow Copy:Operator Pink Copy:LEA <br />