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Waste Tire -j. . ay & Inspection Rep,A Inspection Report Number ■ <br /> o�= State of California <br /> CIWMB <br /> 04/04) <br /> Il — 1140827 <br /> California Integrated 1 Waste Management Board Survey Form - Page 1 <br /> Pert A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> elD- Inspection Type (Fill one) <br /> Site Suffix: 0Z -1 'S j '(� l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ✓� / If Referral,choose referral type(Fill one) <br /> Identifier: 1� � � I�' `�' — 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address Sol l C) <br /> _ / ��y Inspection Date <br /> l CZ.I(Q�1 CA cL�^09 <br /> I Time In Time Out <br /> Business Rep Title ��jj O AM O AM <br /> II � ' JC L/ ® PM vS ®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 /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> O ® Closed 0 Altered <br /> GPS Latitude 0 Hauler I@ Indoor <br /> 0 0 Inactive •Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet ® Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> _ 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 �C-'�tuo <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ! V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 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 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <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 /> 0 O -- - -- <br /> 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/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> 1._,,ection Form Included: 0 <br /> Comments Included: ® V+ �— ---- - Wsn�ature <br /> Business Reps Slgnatur Phone Number __Insp _Phone Number <br /> 41 <br /> INSTRUCTIONS ON BACK i Correct:* Incorrect (- 1 62081 <br /> . . <br /> ■ -- - - -- ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />