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Waste Tire ..dk .,.y & Inspection Rep., t -rtspection Report Number ■ <br /> °`°. CIWMB 81California <br /> (New 04/04) Survey Form - Patuye 1 I 1 - 1143668 <br /> California Integrated Waste Management Board J J <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- " � � �, _ � I Inspection Type (Fill one) <br /> Site Suffix: ` v •l�Jl Routine Q Re-inspection Q Referral Q Observation <br /> Local / ` If Referral,choose referral type(Fill one) <br /> Identifier: (say, , v Iyl (, ' ,� <br /> iiyl L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address - I f ) <br /> loo l lllae ( <br /> ' <br /> 4 C:> c,,l �/ ' <br /> ' ' ` � Inspection Date <br /> `'So''M " q5aIO Time In Time Out <br /> Business Rep Title O AM O AM <br /> P ®PM L/ 0 PM <br /> yl ` QU I V ----- ��r 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) <br /> � 0 Active ® Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ®Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use pContainer <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 ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 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 <br /> CD <br /> I Xv /C <br /> Inspection Form Included: Q' <br /> Comments Included:a• '__/ �rePhone <br /> B sReps Signa uNumber ctor' gnature _ Phone Number` <br /> _- <br /> N" <br /> / - - <br /> INSTRUCTIONS ON BACK <br /> Correct: Incorrect: I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />