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092SSGS0071 <br /> r= Waste Tire Survey & Inspection Report Inspection Report Number <br /> eee. <br /> ee CJWM f181(N w Survey Form - Page 1 I 1 1086962 <br /> ee y 9 <br /> CIWMB 787(New 04104) <br /> Califomla 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: to Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /� If Referral,choose referral type(Fill one) <br /> Identifier: �G.�. �(�(� � l.ra�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> HCltt cc,` s��o� I _ / /�J /� <br /> Ph sical ress L LJTt A--r.IA6 <br /> Street <br /> Inspection Date <br /> L—� <br /> City State ZIP Cooe—� Time In Time Out v fff <br /> Business Rep Title �� I Q AM i —Q\� Q AM <br /> I V <br /> 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) , (Fill one only) •(Fill'all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' v.✓ D ®Active is Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude , ' � � ®Hauler 0 Indoor <br /> O0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ®Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility MENFORCEMENT STATUS <br /> WilA HAULING AND MANIFEST REQUIREMENTS <br /> ® Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB v <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforceme t <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In C-ompliance - No Violations <br /> 0 0 1 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 6 - <br /> Bu Rep's Signature Phone Number In ect Sign <br /> iature Phone Number <br /> ' 62081 <br /> INSTRUCTIONS ON B K Co eet: ant:orreet: EXAMPLE 1 2 3 <br /> White C py:CI Yellow Copy Operator Pink Copy:LEA <br />