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M - Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> CIWMB81California <br /> (N w 04,04) I 1 — 1143520 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 l l:.i 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` v \ If Referral,choose referral type(Fill one) <br /> Identifier: �X,l ��f1'� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r Inspected By Inspector <br /> Physical Address `J . <br /> V&501 S+c:y-\(� � . - - <br /> Inspection Date <br /> Ire, CA 9,531-1 �l m CJ <br /> Time In Time Out <br /> Business Rep Title AM Z AM <br /> C) O PM / 0 PM <br /> ---- -1 - -- -- Operational StatusTire 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 /> ® Active tO Passenger 0 Generator Q Outdoor <br /> --------------- <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler j ® Indoor <br /> D Q Inactive Q Truck � <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 ® Other Auft) A-Ocb2 -y1 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 <br /> 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 /> Q Q 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 /> U <br /> Inspection Form Included: QII ,fir„LN/� v? _ --- -3 <br /> Comments Included. ®-�� /C/Jr/`• A - - .”"-_"""� - -- 68 �6 , <br /> Business Rep's Signature Phone Number I pe r' i ature Phone Number <br /> __ - <br /> INSTRUCTIONS ON BACK Correct: Incorrect i. E X A l1:1/11 ! Z131 62081 <br /> \` '' <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy L <br />