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Waste Tire Sur -.,;y & Inspection Report ispection Report Number <br /> •Ii`�j CIWMB 811(New 04/04) Survey Form - Page 1 I 1 - 1140984 <br /> California Integrated Waste Management Board J <br /> Part-A--Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection J Inspection Type (Fill one) <br /> Site Suffix: `( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sct,>„ �,�..f � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 9 <br /> Physical Address <br /> Inspection Date l C) C) j 0 <br /> CA <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> CA19-4 f3n'1� �v�v(� �' w" 1 a Q O PM PM <br /> (�_ �,,.►�•�-c-..-- - P� cam- - elle- elle- <br /> — -- —- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> ®Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered � <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use 0 ContainerQ Planne <br /> OTR <br /> Business Type (Fill all that apply) <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _ <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> ® 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 Datemi / <br /> / (�i /Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M10 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 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 Q Other: § <br /> Comments n <br /> ��,r�.�•t►,t fz.�tn�T��-iyw ^Cyt r c Glcckz. C.'.�yt�l `F�+- <br /> elle — - - ---— <br /> Inspection Form Included: Q <br /> Comments Included: e X ___- - Cay <br /> - - --- ---. -- --elle-- <br /> - Busines R p S gnature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK orrect:0 Incorrect: X Ak � FC <br /> White C <br /> ■ ® ■ <br /> opy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />