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No <br /> Waste Tire StAy & Inspection Report inspetaion Report NumbeCIWMB 81(Nw04/04, Survey Form - Page 1 I 16 - 10 7 9 1 3 <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile' I Inspection Details <br /> TPID- Inspection Type (Fill one) <br />{ Site Suffix: oTQ } Routine Q Re-inspection Q Referral Q Observation- 7 lo 1 <br /> Local --- i` If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB :Q Complaint Q Educational Visit Q Other <br /> Business or Facility.Name <br /> Inspected By Inspector <br /> Physical Address EF1 I 10 11 <br /> Street <br /> DG�-� �� ���� .l I Inspection Date � <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title - 0 AM 0 AM <br /> ✓v) Vii! l , 1��� 1( / r. <br /> m �0PM m � � 0PM <br /> Operational Status Tire Type Business.Role Storage Type <br /> Tire Count(Whole/PTE) 1�1 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)Q Active @ Passenger Q Generator 0 Outdoor <br /> O 0 Closed O Altered <br /> GPS Latitude m . Q Hauler O Indoor <br /> O Q Inactive (§) Truck <br /> Longitude - I Lil <br /> 0 Planned Q OTR 0 End-Use O Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder ® Other I t7(�Y1. > Jr�(A- <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 /> O O I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O I PRC§42953,Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 010 1 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 O i 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> O U 14 CCR§18459.3 Retention of Comprehensive Trip Logs for 3 years <br /> 0- O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q'Referred/CIWMB Enforcement <br /> 0 , 0 14C R§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> F Q Q 14 CCR§18462-Manifest System Requirements.for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O Q Other: .§ <br /> Comments f 1 p.er iD _ r� �- / / <br /> V. <br /> � yc <br /> i <br /> okl <br /> Tia <br />( lr { ,�� J/ • eft .t,/ � <br /> Inspection Form Included: 0 " <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BASK Correct Incorrect: ] ���; A Mi �P I. lei 5 <br /> r- ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA . <br /> t <br /> i , <br />