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---­--------­- ----- ­................ ----- ----- -- <br /> ................... ............. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIWMBCalif(oNw0 <br /> 4/04) Survey Form - Page 1 1143454 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (ij Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> &D <br /> Physical Addreossyt <br /> � 6 9 J <br /> Inspection Date 41 <br /> 2�::' _Ch/v Time In Time Out <br /> , kzX_yN'f CA <br /> = <br /> usiness Rep Title 0 AM Am <br /> V <br /> 0 PM 0 PM <br /> CLA194< 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) Active Passenger ®Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 inactive ® Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer (M Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 car Dealer 0 collection 0 crumb Rubber <br /> 0 service station 0 Hauler 0 Agriculture 0 Shredder Other ;0 <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V_[_AHAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation <br /> oce 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC 1§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> C <br /> 0 014 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EX7) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators @Yin compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> 0-0 <br /> Inspection Form Included: O� <br /> Comments Included: <br /> Business Rep's Signature one Number Ip t jj;&urre� — ------Phone Number <br /> 1112131 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: [E i1A M L <br /> White Copy:CIWMB Yellow Copy:Operator Pink(npk-IILJ <br />