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Waste Tire Sur y & Inspection Report ispection Report Number <br /> CIWMB 81California <br /> (N w 04/04) Surve11 — 1140584 <br /> California Integrated Waste Management Board y Form - Page 1 <br /> Part A- Survey -_ - BLUE OR BLACK INK PEN <br /> [Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (^sy .J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Nam - <br /> j Inspected By Inspector <br /> ✓ fLC�r-SC..C/l� �/'GGC'-�C>� -�-s�G- it <br /> Physical Address - <br /> Inspection Date t �l <br /> Time In Time Out it <br /> Business Rep Title 0 Cj 0 0 AM C1 0 AM <br /> ® PM Is PM <br /> ✓ - -- Operational Status! Tire Type Business Role I Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator Outdoor <br /> Latitude 0 0 Altered <br /> GRS D Closed -0 Hauler 0-tndoor- <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 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 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility f ENFORCEMENT STATUS <br /> t V A 'HAULING AND MANIFEST REQUIREMENTS 0 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 EXT) <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 /> 00 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 ,Compliance No"Violatiops <br /> 0 0 Other: <br /> Comments &11) <br /> 'y�,r>:, <br /> Inspection Form Included: oI <br /> Comments Included: <br /> - -- <br /> Business Rep's Signature Phone Number Inspector's Signatu Phone Number <br /> INSTRUCTIONS ON BACK Correct lnorre+�tz .' { - , 2 3 s2os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy. <br />