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0321705004§ <br /> '!HB- <br /> Waste Tire Su ey & Inspection Repo Inspection Report Number <br /> HH� ate of Cafifornia <br /> CtIWM6 81(New04t04) Survey Form - Pa ' e 1 I1 1086945 <br /> California Integrated Waste Management Board ! J <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O ` Inspection Type (Fill one) <br /> Site Suffix: 3[3 <br /> `1 Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �aA J _ � `- 11 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `vim Inspected By Inspector <br /> L e\ _ _ <br /> Physical ress <br /> w. <br /> Sheer <br /> �Q Inspection Date <br /> S <br /> City ��o C\ —CA_ <br /> Sfete �ZIN Cor�2� Time In Time Out <br /> Business Rep Title AM m . I ) O AM <br /> 11j3---- i 0 PM I I I ( 0 <br /> PM <br /> `,`O- --- - o -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> f ' ®Active ®Passenger ® Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> A* New Tire Dealer Q Auto Repair Q•Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IIIENROMAEMEMT STATUS <br /> V A HAULING ANDMANIFEST REQUIREMENTS <br /> ® Notice Of violation Q Extension <br /> Q Q <br /> 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 O O <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIW MB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> I- Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 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 Q 1 Other: <br /> Comments <br /> 01- gLlel.o�_ q�Za a o =t IO <br /> Inspection Form Inclu + <br /> Comments Included: —� l�— — � - �`� v-`77 <br /> B siness`Rep-s na ur Phone Number ��spjt�olslignature Phone Number <br /> INSTRUCTIONS ON BACK Corr ct: correct: 62081 <br /> EXaP ;LE 1 ,123 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:LEA <br />