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Waste Tire Sui .ay & Inspection Report, ,InspectionReportNumber <br /> fornia E <br /> CIWMB 811(New 04/04) SurVe Form - Pa[�e 1 I 1 - 1143544 <br /> California Integrated Waste Management Board Y J <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ® Routine 0 Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: Sw, co./n1 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 J l Inspected By Inspector <br /> � <br /> Physical Address C – <br /> � 1 l O Ara Mb <br /> Inspection Date F <br /> CA ct5,2,s ( Time In Time Out l CJ <br /> Business Rep Tii+tllee,, / + ® AM AM <br /> �e a "`l Gl CJGr 1 MG, l ( f✓ O PM— O PM <br /> � � Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) td (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> C� <br /> IS Active @ Passenger 0 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive •Truck <br /> Longitude – Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0-Trucking Fleet Q Government O Retreader _0__D_ismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder ® Other - - <br /> L.yt, �cr.P,1�1c�_!-1c..�-, <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 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 i Date m / m / m <br /> 0 0 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 /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q O1 Other: § <br /> Comments <br /> n4 Ifil <br /> Inspection Form Included: QI <br /> Comments Included: -------- - - -- -- <br /> B iness Rep's S' nature Phone Number or' i ature Phone Number <br /> INSTRUCTIONS ON BACK C recta Incorrect { , 62081 <br /> X_� - __ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink±0111� <br /> ® ■ <br />