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t.grg Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB,B,steM nage ....Survey Form Page 1. 1 7 1 0 0 6 4.4 a <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile _ _ - Inspection Details, <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L4 3 (j o ; ' 0 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 0 Other <br /> Business or Facility Name Inspected B <br /> - p Y Inspector <br /> Physical Address _ <br /> _,5 tS __ •.�__ p <br /> Inspection Date b 7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �r1n✓� lx ® p ®PM O PM <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 /> f 0 Active Q Passenger Q Generator i Q Outdoor <br /> Latitude 0 0 Closed Q Altered <br /> 0 <br /> GPs Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> BusinessTvpe (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection 0 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 /> A HAULING <br /> AND MA RQUFREMENTS <br /> 0 0 0 Notice Of Violation Q Extension <br /> 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 m m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-The Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days Require for NOV or EXT) <br /> 0 -0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities r <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance_ Violations <br /> 0 Other §10 <br /> ._ _l. <br /> Comments -kCat`QV � 1 <br /> Inspection Form Included:Q 2-227- p <br /> Comments Included:0,A <br /> Busies Signature Phone Number Ins Phone Number <br /> - - - <br /> INSTRUCTIONS ON BAC Correct: incorrect: �/ € ,` ` 31 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ® ■ <br /> 0525804.0154 <br />