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Waste Tire Survey & Inspection Report •nspection Report Number ■ <br /> @88 State California Survey Form - Page 1 T 1 - 1141008 <br /> CIWMBB 181(New Y <br /> California Integrated Waste Management Board <br /> Part A-Survey - BLUE OR BLACK INK PEN. <br /> siness Profile Inspection Details <br /> .'ID- � � � � � � I Inspection Type (Fill one) <br /> � � <br /> Site Suffix: — Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S�n J Vr c alJl (Wf4l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 16 J <br /> Inspected By Inspector <br /> Physical—Address — i V I �� <br /> W . 0,Nq0f\ f4, <br /> 1^�CL� Inspection Date ' V V V ! O <br /> ' Time In Time Out1 <br /> Business Rep �Title 0 AM AM <br /> O PM I "1 p 0 <br /> � V O PM <br /> l <br /> )i,Ck W 0J4) CRS QTc S,4�V� — --- <br /> J 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 ® Passenger ® Generator t' Outdoor <br /> Latitude ® Closed 0 Altered <br /> GPS Latitude Hauler �i � Indoor <br /> O 0 Inactive Q Truck <br /> Longitude — 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j 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 <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 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/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 4 In Compliance - No Violations <br /> 0 0 (Other: <br /> Comments <br /> .,ection Form Included: 01 - <br /> Comments Included: <br /> Z4R Y�9 ySo2 <br /> Business Rep' Signature Phone Number lnspecto Signature Phone Number _ <br /> INSTRUCTIONS ON BACK Correct: Incorrect p (� 62081 <br /> X [�T�T�1TJ III T� <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® . <br />