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Waste Tire fty & Inspection Re of Inspection Report Number <br /> i State California I - 1143635 <br /> CIWMB t81(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey_-- <br /> Business Profile Inspection Details <br /> - — — <br /> TPID- ., „ Inspection Type (Fill one) <br /> Site Suffix: ' ►� l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ` \^ If Referral,choose referral type(Fill one) <br /> / <br /> Identifier: 14a, �] 1,C ice' { w(/YL L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> DC7 S —r- c�' . (] d J7 (�,Qj <br /> � <br /> Physical Address �Y�XLyy) �(��C� <br /> 5(X)v <br /> Inspection Date 3 / 0 C7 / f`t <br /> �1 � � Time In Time Out [ �J <br /> Business Rep Title f h •AM AM <br /> O PM � PM <br /> l l! Q b <br /> - - -- - - -- --- -- -- - Operational Status Tire Type Business Role Storage Type <br /> ® (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 1 <br /> ® Active Q Passenger ®Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> D Q Inactive 4D Truck I <br /> Longitude - Q Planned ® 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 ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility LENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB IBJ <br /> F I / <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> ® 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 Q in Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Ave— <br /> - -- <br /> Inspection Form Included: Q� &Ir <br /> --- y� <br /> Comments Included: ® _ -- - <br /> sine Signature Phone Number tur Phone Number <br /> 62081 <br /> ' 111213 <br /> INSTRUCTIONS ONBACK [Correct:0 Incorrect: � I <br /> — - - ® ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />