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} :6= " Waste Tire Suri & Inspection .Re o Ispectlon Report Number <br /> r� : p p <br /> 68F8j�. State of California <br /> CIWMB 191(New 04/04) Survey Form - Page 1 i " 5 - .4 0 -1 '3 5 1 7" <br /> +�. California Integrated Waste Management Board , <br /> Jia Part•A- Survey f BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> R ° TPID- Inspection Type (Fill one) <br /> Site Suffix: � J C/ ,c" -� EE Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: `�,-.„ ?..• - } Q CHP .0 CIWMB Q Complaint Q Educational Visit Q.Ether <br /> Business or Facility Name <br /> L Inspected By Inspector <br /> Physical Address L—L{-J ' �-, , / ! /jc CX-01 <br /> Street _ <br /> Inspection Date <br /> Cit State ZIP Code Time In Time Out <br /> Business Rep Title m L—L_J D_AM OAM <br /> PM m PM i <br /> - — - <br /> I U Gr<.7 - -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (9 Active Passenger Q)Generator Outdoor <br /> m C O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 ` <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other �• <br /> II <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 /> i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> -0., .Q PRC§42956.-Registration/Decal in Vehicle <br /> Q Q 14 CCR-§-•18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q. Q 14 CCR-§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest•System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (fi In Compliance - No Violations <br /> Q 1 0 lOther: § <br /> Comments (��� , �( �� `6'''<�_�,-J�,_ ��. ��•C�? �••:-/�.r ��,�.'<.�-- to �-^ ��z�_� <br /> t e, t7y5 r� t..1- C t �cS 0 C <br /> DIf <br /> nspection Form Included: : - <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbe, <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �] E,r',X �t,;l P. ,L 1, ?. 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />