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Waste Tire .E r :y & Inspection Repc Inspection Report Number <br /> State of California �, <br /> CWMB1(New04/04) Survey Form - Page 1 I 1 - 1140610 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> / z 3 _ 1 Inspection Type (Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c. �� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected-By - <br /> Inspector <br /> iessPhys- - 3 <br /> 2 9 N <br /> Inspection Date ` Q / r 0 <br /> S Ito C�} fs2io <br /> Time In Time Out <br /> Business Rep TitleAM O AM <br /> > <br /> *0 'PM2 0 0 0P <br /> --- Operational Status Tire Type <br /> IBrssRole Storage <br /> Tae <br /> (Fill one only) (Fill allat apply) ( ill all apply) i ( alapply)y) <br /> Tire Count (Whole/PTE) Y <br /> ® Active ® Passenger . Generator . Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler • Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - O End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® 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 f ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O 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 /> O Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <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 /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance- No Violations <br /> O O (Other: § - <br /> Comments <br /> Inspection Form Included: <br /> P O <br /> Comments Included: ® <br /> Business Rep's Signature Ph ne Numbdr spector's Signature PFione Number <br /> T 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X 'X A 11 12 3 <br /> White Copy.CIWMB Yellow Copy.Operator Pink Co :L <br />