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i; Waste Tire SL- .ey & Inspection Repor , Inspection Report Number . <br /> CIWMe81California <br /> (New 04/04) Survey Form - Page 1 I 1 - 1144020 <br /> California Integrated Waste Management Board J g — - - <br /> -t A-Survey _ _ - __ . BLUE OR BLACK INK PEN <br /> :iness Profile Inspection Details - - <br /> I"PID- Q -Q Inspection Type (Fill one) <br /> Site Suffix: J V �I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ` I If Referral,choose referral type(Fill one) <br /> Identifier: w1� `E1l,�l.R�f- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ! Inspected By Inspector <br /> Physical Address ( C l C) r At" /4mm,6,L4, <br /> /v2 �et G/e(vlYN <br /> ice, / ,q r Inspection Date C) l <br /> (�� t01 , CA c75-Ro6 Time In Time Out <br /> Business Rep Title &AM AM <br /> 1 I ' 0 G 0 P 1 C 0 P <br /> - -- ---- ----- -- — — ---- -- -- - -- Operational Status Tire Type i 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> - - --- O ® Closed Q Altered Ajq 1/,41 <br /> GPS Latitude kQ Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> J Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Q 'Q Notice Of Violation Q Extension <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 M <br /> Q Q 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 /> 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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities j <br /> i <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - Na Violations <br /> Q Q Other: § <br /> Comments <br /> Fspection <br /> Comments Included: Q 7V <br /> Re nature - Phone Num I S. or' ilj ture L?Q --Y�e Number <br /> _ - - - - <br /> INSTRUCTIONS ON BACK Correct: orrect 62os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />