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r Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB I 1 - 114 4 0 0 5 <br /> California Integrated WasteManagementBoard Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK_INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- � � � " � � � _ O � Inspection Type (Fill one) <br /> Site Suffix: t'` 40 Routine 0 Re-inspection O Referral O Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: �q Y o u,n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> ? Inspected By Inspector <br /> Physical Address l l a6) CSS <br /> �� ����� Inspection Date <br /> U1.nlJX�J\ Time In Time Out <br /> Business Rep Title O AM 0 O AM <br /> 0 PM 6�PM <br /> - - <br /> Operational Status Tire Type- - - - p yp Business Role Storage Type <br /> Tire Count(Whole/PTE) I 5 fl (Fill one only) (Fill all that apply)j (Fill all that apply) (Fill all that apply) <br /> �f <br /> - - --- � Active Passenger 40 Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer • 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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility i EINFOR-CERENTSTATUS- <br /> Vj A I HAULING AND MANIFEST REQUIREMENTS <br /> j <br /> O O 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. I Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FP / M / M <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 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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 U <br /> Comments Included: 0I �Signature <br /> usiness Rep's Phone Number Inspec is Signature Phone Number <br /> - - - - -- <br /> - - 62081 <br /> INSTRUCTIONS ON BACK ! Correct: incorrect: i f ?{ �4 ,4IS =t� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y: ® ■ <br />