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■ _ Waste Tire Survay & Inspection Report (nspection Report Number <br /> ��WMBCalifornia <br /> 11(New04104) Surve Form - Pa e 1 Il - 1143625 <br /> California Integrated Waste Management Board Y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- es <br /> Inspection Type (Fill one) <br /> Suffix:Site `� �p ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r 1 rIf Referral,choose referral type(Fill one) <br /> Identifier: C!(1 J L0 r) Wu� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �u)C_V�� 5 Lai, 3 9 - o i <br /> Physical Address <br /> O�` �� Inspection Date <br /> Time In Time Out <br /> Business Rep Title q * AM 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �r�( (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered NA <br /> Latitude Q Hauler Q Indoor <br /> O Q Inactive � Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 90 `j } <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 r U <br /> 1-CJ,J°r J <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ;-ENFORCEMENT STATUS <br /> V , <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension I <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. iiCompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle I <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Datem / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <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 �,� - t �@- -� l� l <br /> I 1naV A: <br /> Inspection Form Included. 6 <br /> RQ S� 0 5'r1 - • (a(Comments Included: — li, <br /> i Business Rep's Signat Phone Number In4$etu Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />