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Waste Tire Su. - ay & Inspection Report r,,nspection Report Number ■ <br /> CIWMBState California Su rve Form - Page 1 Il - 1140710 <br /> 787(New 04/04) y <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection D Inspection Type (Fill one) <br /> Site Suffix: i O 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalSeL11L— <br /> / If Referral,choose referral type(Fill one) <br /> Identifier: pipc y=, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name C <br /> Inspected By Inspector <br /> Physical Address <br /> 9S Q Inspection Date <br /> Time In Time Out <br /> Business Rep Title S AM I AM <br /> Q PM / O PM <br /> ----- -- - -- - - - --- ---- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) J <br /> Active � 0 Passenger 0 Generator Q Outdoor <br /> ---- -------- O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> • New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 40 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 /> I-V-1 A 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 <br /> 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 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 49 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> L.`" 'y tea r✓nG�i�r / - �i7 1�D r't.�tc,ya�t [[/a�'�-L r�� - <br /> /J S 6�i't�,/t.1 Gy►-y Orc �� c; '4-tr`�� i'8��. <br /> Inspection Form Included: Qj i �E79 <br /> Comments Included: Q� - - - <br /> usiness Rep's Signature Phone Number Inspector's Signature Phone Number_- <br /> INSTRUCTIONS ON BACK Correct. i I Incorrect. <br /> V-1 E X A M.....TL _. 1 ! <br /> 213162081 <br /> 0 White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ® 0 <br />