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Waste Tire Sul .ey & Inspection Report. Inspection Report Number � <br /> CIWMB81California <br /> (New04/04) Survey Form - Page 1 I 1 - 1143655 <br /> California Integrated Waste Management Board Y <br /> Part A- Survey _ BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- Inspection O Inspection Type (Fill one) <br /> ffi - - - -- - <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local \ jj�_G�{. If Referral,choose referral type(Fill one) <br /> Identifier: ��� J �� (- n O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical�Address� e� 59 <br /> � �v �rc(,►nbv�1 <br /> mcoc) E- Lt )et -L, CU , <br /> Inspection Date � � � j <br /> Go,k'�- CA Q,563 <br /> Time In Time Out <br /> Business Rep / ,, Title <br /> Z /� O AM � � � � Q AM <br /> � VCty1,1`L1'.7lJ�i✓1 CJ7J'I1�. ��• � � V O PM ® 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 /> r - •Active- -Q Passenger ® Generator 0Outdoor <br /> � Q Closed 0 Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> O O Inactive ®Truck <br /> Longitude - O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler O 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 O 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 <br /> i Q Notice Of Violation Q Extension <br /> O 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 /> 0 O 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 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: 01 �Oq- 6p <br /> Comments Included: r - ----! 1 - (J .c67_ _ <br /> - -- - — - - - <br /> INSTRUCTIONS O Business Rep's Signature Phone Number - In tor' nature Phone Number <br /> N BACK Correct:* Incorrect �/ J J E X I A MI V nature <br /> T �13! 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:W ■ <br />