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Waste Tire Su ey & Inspection Repo Inspection Report Number ■ <br /> ■ iI1 State of CaliforniaCIWMB 181( ew 04/04) <br /> T 1 <br /> California Integrated Survey Form - Page 1 yi 1140750 <br /> d <br /> Part A-_Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t � � Q O � Inspection Type (Fill one) <br /> Site Suffix: l • Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� 1 O�/urn (01A, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> A` 101gen <br /> Physical Address Es A& <br /> -- —-- ---------- - ------------- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM O AM <br /> 1 I L 0 P 0 P <br /> — --- - -------- — ---- 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 /> 4D Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 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 /> ® 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 <br /> 0 0 § - � Notice Of Violation 0 Extension <br /> PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 EX7) <br /> 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 /> i <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 rtA� 1Wf44, QTc I n I I Q, CW4 <br /> Inspection Form Included: <br /> �Jlojj• � �-- - c �U--3 C 7 ti <br /> Comments Included: �� <br /> Business Rep's Signature Phone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect I � E X A P f 2 3 62081 <br /> -- X _ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: ® 0 <br />