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Waste Tire Survay & Inspection Report Inspection Report Number <br /> CIWMB 811fornia(New 04/04) Survey Form - Page 1 I1 - 1144018 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` L 3 g J - V Q Routine i Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName -- -- <br /> Inspected By Inspector <br /> Physical Address �, <br /> goo *on Poll To N <br /> Inspection Date 03 <br /> Time In Time Out <br /> Business Rep Title G ®AM /� L 4 AM <br /> t O PM / �V G O PM <br /> -- - — - --6rr"fet _i Operational Status (ire Type Business RolleStorage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) Fill all that app Iy) Fill all that apply) <br /> (Fill all that apply) <br /> 10 C/.J, <br /> Active ® Passenger *Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR A End-Use Container <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 Other1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> I <br /> QV A §HAULING AND MANIFEST REQUIREMENTS <br /> � <br /> Q - Q Notice Of Violation Q Extension <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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 In Compliance - No Violations <br /> Q Q Other: § _ <br /> Comments <br /> Inspection Form Included: 6 n <br /> Comments Included: O � `-26 <br /> �y� <br /> sine ep's Signature Phone Number s c r' ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: Lf,+ 1V A M i L 1 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy ® ■ <br />