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sgfornia <br /> ki <br /> Inspection Report Number <br /> Waste Tire Su*y & Inspection Report; <br /> y CIWMBState f 811 <br /> (New 04104) Survey Form - Page 1 I 1 - 1141294 <br /> California Integrated Waste Management Board J <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r L` 1 - o J Inspection Type (Fill one) <br /> Site Suffix: / L ® Routine 0 Re-inspection 0 Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> .e ,�,• I 1I _ _ Inspected By Inspector <br /> ll Va�� IILSC <br /> Plhlysical AdOress <br /> Avc <br /> Inspection Date G <br /> / Time In Time Out <br /> Business Rep Title '? ? O AM - C- O AM <br /> ® PM ® PM <br /> ejt,C�, I I � <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 /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned Q 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 /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other �n ,K _���A - <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility (ENFORCEMENT STATUS <br /> OV DA HAULING AND MANIFEST REQUIREMENTS <br /> _.— _ __.__. ........... (� Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRQ§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 I Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> -_.._ - , --._.._.___ __._. <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 1 CIWMB Enforcement <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 <br /> In Compliance - No Violations <br /> Other: § -- - ---- <br /> Comments <br /> J <br /> Inspection Form Included: 0f <br /> Comments Included: Q �ICt� ,-� `�' ` - ` 73 <br /> B siness Rep's Signature Phone Number . In ors igture Phone Number <br /> � <br /> INSTRUCTIONS ON BACK Correct: Incorrect. �/� "X' F 2 62081 <br /> X ` <br /> White Copy:CIWMB Yellow Copy:Gperhtt5r Pink Co y:LE <br /> �; <br />