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Y <br /> Waste Tire Su 3y & Inspection Report Inspection Report Number ■ <br /> CIWMB81California <br /> (New04/04) Survey Form - Pa e 1 I1 - 1140711 <br /> California Integrated Waste Management Board <br /> Part A- Survey - -_ -__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- +` Inspection Type (Fill one) <br /> Site Suffix: 1 0 -� `[ 7j -1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ,` ! 3 cl <br /> 3o3o <br /> Inspection Date 0 3 G <br /> Time In Time Out <br /> Business Rep TitleO AM O AM <br /> I <br /> j ` I jj��,,�� 0 PM Z q L 0 PM <br /> - --- -- - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' 1 1@ Active Passenger- ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 Q Auto Repair Q Trucking Fleet Q Government Q 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 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 EX7) <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 i 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 9 i Compliance - No Violations <br /> Q Q Other: § <br /> Comments�� <br /> _ 1Vy d f D l a� tSY\ OY Y�C1 S Cl( <br /> Inspection Form Included: QI 011 Ug <br /> Comments Included. Q — rC_ <br /> Business Rep s Igna ure Phone Nuumber✓ spector's Sig_natur Phone Number <br /> w` r \" <br /> i * — - - 62081 <br /> ■ INSTRUCTIONS ON BACvKitei Copy: wMe InCOroeCCopy:Operator (' I ® ■ <br /> Pink Co y: <br />