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08227044118 <br /> °= Waste Tire Survey & Inspection. Report Inspection Report Number <br /> ctr_ <br /> rr CIWINI IBI(omia Survey Form - Page 1 I1 1088385 <br /> CalifartNa Integrated Waste ManagameM Board Part <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID �I _ I Q / Inspection Type (Fill one) <br /> Site Sutfix: IIII "'r IIII 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 'AT1 If Referral,choose referral type(Fill one) <br /> Identifier: V�a •� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business1;'S <br /> cility Name — � Inspected By Inspector <br /> '7'4vl a <br /> Physical Address I l Q I I�� &� <br /> Street1 <br /> eCO— 6q /6-Jt/� Inspection Date I O / �/� / O f( 1 <br /> Cifty State ZtP Code Time In L Time <br /> Outt CJ <br /> Business Rep Title 0 AM l 0 AM <br /> rQ" --- t�- — 1-----;0 PM 1 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WhOIeIPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t r O O 0 Active Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude - ®Hauler Q Indoor <br /> -_ -_-- O Q Inactive ®Truck <br /> Longitude - I Q Planned ®OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> ®Service Station Q Hauler Q Agriculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice of Violation Q Extension <br /> 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 FX7) <br /> 0 O ----- - - ----- -- <br /> 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!GI 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 /> Q Q 1 Other. § _ <br /> Comments <br /> RO_ _ <br /> kc <br /> e �VJL1V/ r W_aS e �W G rp�h✓101ft O S—5 . ��f��nZ S ✓l Py1J . <br /> L m r` fo `r ahs / Scat w <br /> C7� ,{�r s v� � e_h f� _ems <br /> Vol- eS,/ISI_ La tin_ n - - <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspect 's Signature Phone Number <br /> INSTRUCTIONS ON BACKCorrect:INIIncorrect: X AIMI AIMP I L E I .2 362081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br />