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Waste Tire Su. .ey & Inspection Report Inspection Report Number <br /> State of California <br /> = CIWMBSurvey Form - Page g 1 Il - 1143605 <br /> California Integrated Waste Management Board <br /> Part A- Survey__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- © Inspection Type (Fill one) <br /> Site Suffix: `� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: SciC�c�� CWT L 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address A l .? 1►� __(� <br /> Inspection Date `Z O <br /> Time In Time Out <br /> Business Rep Title 6 AM •AM <br /> c;C -7 O PM l C J 5 9 0 PM <br /> ----- -- -- -- — — Operational Status Tire Type Business Role Storage Type <br /> v (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 0 <br /> 10 Active ®Passenger 40 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive ®Truck j <br /> Longitude — 0 Planned o OTR ® 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 ® Other ,"te �,,l <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS ® Notice Of Violation 0 Extension <br /> 0 . 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle -16 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / / 51� <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> [3 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EXT) j <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 0 In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 01 QQ 2 ^ <br /> Comments Included: ®� 9 C-16 �7 <br /> Busi&sep's Signature Phone Number I` ct r ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � A e X P i L 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />