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Waste Tire Suty & Inspection Report Inspection Report Number <br /> a <br /> State of California 1 � 9 4 A 4 <br /> CW <br /> ew 04/04) <br /> CaIfoma Integrated WasB 181 tJeanagement Board Survey Form - Page 1 I - 4 <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile " d Inspestiptt Details <br /> Inspection Type (Fill one) <br /> Ste Suffix: I 'fi 7 -� (S Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 111 _r-t-=- �_T f`' If Referral,choose referral type(Fill one) <br /> Identifier:.. v'I G)C I.f,{t r�. I` tf t r, j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> tusiness or Facility Name _/ <br /> Inspected By Inspector <br /> r <br /> Physical- Address <br /> Street <br /> Inspection Date <br /> City State 7PR Codi, Time In Time Out __.__.. <br /> Business Rep �L ,; c t Title{N',.t a " ,� t/ AM ^- AM <br /> PM <br /> iL Operational Status Tire Type I Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all thatappl# (Fill all that apply) (Fill all that apply)' <br /> ��� Q Active 0 Passenger0 Generator 0 Outdoor <br /> - O 0 Closed 0 Altered <br /> GPS Latitude dd 0 Hauler 0 indoor <br /> 0 Inactive 0 Truck <br /> I - -�--1 I-- --�—r- o <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 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 (5) OtherY�7il� <br /> 3 -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / F7 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O - --- _ <br /> 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 i 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 0 In Compliance - No Violations <br /> 0 0 (Other: § <br /> Comments <br /> r� <br /> Inspection Form Included: 0'' <br /> Comments Included: 0 - <br /> Businesi Rep� signature' Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:i Incorrect: X - L i i - 62081 <br /> ■ ® S <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy'LEA <br />