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■ inspection Report Number <br /> Waste Tire Su, ,►may & Inspection Repos <br /> CIWMB 81'fo(New'1114) SurveyForm - Page 1 Il <br /> - 1143833 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey - .. - --- --- - <br /> �Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I p2 l�( 1 Q Routine ® Re inspection Q Referral Q Observation <br /> Local C CO�� If Referral,choose referral type(Fill one) <br /> Identifier: J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phys� -� /�� G <br /> l ddre s W►� ✓2 U LL� S 1 l l /� TC�uCJ iTr�t✓►'l bL� <br /> Inspection Date <br /> q5,:?05 Time In Time Out <br /> Business Rep Title r, ®AM ®AM <br /> _ ,� O pM Q 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) f I� <br /> 0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 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 ® 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 /> 0 14 -CCR§18459 Responsible Entities Complying with Manifesting Requirements Date / M10 / I I �'► <br /> I Ylyl <br /> Q O 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 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 /> QO 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 Q In Compliance - No Violations <br /> Q Q Other: § — - <br /> Comments <br /> Inspection Form �nc <br /> ncluded: Q <br /> Comments luded: - -�3� 1 - i� <br /> B s�esnsRep's Signature Phone Number 0o ' re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �; �/! E X A1White Copy:CIWMB Yellow Copy:Operator Pink ® ■ <br />