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Waste Tire Su. - ay & Inspection Report Inspection Report Number <br /> g" CIWMB 811ifornia(New04/04) Survey Form - Page 1 I 1 - 1143995 <br /> California Integrated Waste Management Board J J <br /> Part A—SurveyBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- { O ^t -7 Inspection Type (Fill one) <br /> Site Suffix: 1 J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r- If Referral,choose referral type(Fill one) <br /> Identifier: (A{� `B Q U, U!1 <br /> �J � n � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physicall ess <br /> Cv i (`�- 301 I n t r <br /> A <br /> Inspection Date <br /> -jr��� �q R53-76 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> n (, \ \ � `l 5 � <br /> rS � � S ® PM PM <br /> J - - - - - -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> -1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � o� <br /> t ' ®Active ® Passenger (a Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government (n Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder - Q Other <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> OII ® _ - - - <br /> 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 /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> O Q (Other: § <br /> Comments <br /> )_ II <br /> - <br /> S(61 (Iz� of3 3� `( _ b9 ql 1 Oq <br /> Inspection Form Included: Q 9 <br /> Comments Included. I*' <br /> Business ep's gnature one Number_ Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: A P (_ 62081 <br /> • <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:L <br />