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= Waste Tire Su► ay & Inspection Report Inspection Report Number ■ <br /> LLL3. <br /> State B CaliforniaCIWI 1 - 1143691 <br /> 04/04) <br /> California lnt g MdWaseeManagementBoard Survey Form - Page 1 <br /> Part A- Survey -BLUE OR BLACK INK PEN <br /> Business Profile (Inspection Details <br /> TPID- ( f� f /� (� _ Q I Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine I* Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S 6Q) J Q ttlk Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> U` �� Inspected By 1 Inspector <br /> Physical Address�eS J I ` 0 <br /> Inspection Date I 1 <br /> Time In Time Out <br /> Business Rep 1 r Title O AM O AM <br /> �� <br /> � --- - PM— - o �. PM <br /> GIQ - <br /> - -- --y- - — � � Operational Status Tire TypeBusiness Role Storage ge Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active ID Passenger Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler 11* Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Is 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 PMI keMoA O� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I 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 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 i Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> QQ j 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 19 l bI Qa-1 P 4: i01\ ()CSku S(`( eA <br /> On� C <br /> Inspection Form Included: Q <br /> Comments Included: Q -- -�`-3a��3 $ <br /> Business Reps 5 ature Phone Number Inspec r s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct_* Incorrect X " ' , }C t h4 l 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />