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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 0 8 0 8 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> `A- Survey_ BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> „ <br /> ID- Inspection O Inspection Type (Fill one) <br /> Site Suffix: 6 Z t Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> BusinessL or Facility Name Ile <br /> Inspected By Inspector <br /> Physical/Address �l - <br /> �� <br /> Inspection Date <br /> �7UC �r� CIA <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I ;21 ® PM U r a ® PM <br /> J_ Tire <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 /> ' Z Q Active Q Passenger Q Generator Q Outdoor <br /> O 9 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ,ew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ised Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ._.. .... 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / 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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 1010 1 Other: § <br /> Comments zh i /1'V &j-7 474,r r <br /> h. ,_action Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature — Phone Number 4nscto=ssnature Phone Number. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X F- th4 P �.1T3_1 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />