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Waste Tire Su. . JAY & Inspection Repoi . Inspection Report Number <br /> =a�= State of California Il — 1143987 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection details <br /> TPID_ Inspection Type (Fill one) <br /> Site Suffix: l I ` 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local /, If Referral,choose referral type(Fill one) <br /> Identifier: �� L/M l � ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> CA }} Inspection Date <br /> ��_ l Time In Time Out < C <br /> Business Re(p�. l �[ Title f L 0 AM 1 O AM <br /> 1'C, R 6 IC�J`l Im oc"Yl c 4 ( l J O PM t L O PM <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger 0 Generator ®Outdoor <br /> GPS Latitude Q Closed j Q Altered <br /> Q Hauler Q Indoor <br /> p Q Inactive 0 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 ® 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 4' Other <br /> ----- ---- -- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> V T A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 I (Required for NOV or EXT) <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 1 Q Referred f 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 l <br /> in Compliance - No Violations <br /> Q Q Other: § <br /> Comments S/''`e / )M n W <br /> Inspection Form Included: Q <br /> Comments Included: 01 - <br /> usiness Reps Signature Phone Number In p ctor ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I X A P! i 1 S 1213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />