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= Waste Tire Su. ,ey & Inspection Repor. Inspection Report Number ■ <br /> State of <br /> 181fornia <br /> (New 04/04) SIl - 1127725 <br /> E:. <br /> California Integrated Waste Management Board urvey Form - Page 1 <br /> Part AL- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i -� l I 0 Routine ! Re-inspection Q Referral Q Observation <br /> Local 1 ` q / If Referral,choose referral type(Fill one) <br /> Identifier: — � �- V t� C.CJL Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> iiar <br /> Physical �sn ' n5P o l� l ���:r��-L/ " <br /> �y f� Inspection Date <br /> �-�Ci� ' l �V J CJ 6 �✓ <br /> Time In Time Out <br /> Business Rep Title / / AM AM <br /> ��. ! O G O PM 0 � 3 O PM <br /> ; . -7 trl� OFFS — -- ---- <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 /> ' ( ®Active O Passenger • Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair ®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 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA J HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q 0 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 /> -------- -.._.--- <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ------- --- - - - <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> OQ 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 010 Other: § <br /> Comments <br /> Inspection Form Included: 11j_^t 2 <br /> - - - - Zoe r'-l-(( 3 <br /> Comments Included: Business Rep's Si ture Phone Number or' nature _ -_ Phone Number <br /> INSTRUCTIONS ON BACK [o rect. Incorrect: �1 X A � � � 62081 <br /> `� <br /> ■ White Co y:CIW Yellow Copy:Operator Pink opy:L ® ■ <br />