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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMB 81(Nw04104) Survey Form - Page 1 I 1 - 1143702 <br /> California Integrated Waste Management Board <br /> P-rt A- Survey - BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> I HD- I Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local r— 1 If Referral,choose referral type(Fill one) <br /> Identifier: �kf) J Q L�1n �llU� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� ] Inspected By Inspector <br /> VO,`flz 1 SCp�l� \ S eJ�cr V W"1 D 11 I ' <br /> Physical Add s .] EsCob <br /> Inspection Date <br /> Time In Time Outy <br /> Business Rep Title ') O AM l O AM <br /> PM 1 go PM <br /> - --- - - -- - --.Operational Status'I 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Closed QAltered NIA indoorGPS Latitude Q TrucQ/rQ Hauler <br /> Longitude 0 Q Inactive Q OTR k Q End Use Q containerQ Planned <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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber I <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 /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> 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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> I <br /> �..�pection Form Included: Q <br /> Comments Included: - ---- - ------ Jhoqn�e�NumberBusiness Rep's Signature Phone Number Inspe is Signature <br /> i - -- -- 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: L! }C A M P'� - ! 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />