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Waste Tire Sur.jy & Inspection Report Inspection Report Number <br /> tli StateBCalifornia Surve Form - Pa e 1 T 1 <br /> CIWMB 1 a fNew 04104) Y [� 1 .L 112 7 8 9 5 <br /> California Integrated Waste Management Board aJ <br /> Part A- Survey _-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> _ Inspection Type (Fill one) <br /> Ste Suffix: 0 � L7 � � � � Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��Q ✓\� �'�'� %I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address A ?O7uC7 "!"uY�tJ(� <br /> Inspection Date ] 1 C j C <br /> h'r,nc'lX &Lmo- A �lst r l l <br /> Time In Time Out <br /> Business Rep ffTitle ` 0 AM ,; 0 AM <br /> �ert �-�'VM\�� U � -L �i'�evi$t9✓ t� LI � � PM � � � ® PM <br /> - -e- - - - --- - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) \ �j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ` ✓ 0 0 Active 0 Passenger 4V Generator Outdoor <br /> O 0 Closed 1 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive �Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) _ <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension <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 /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O --- - <br /> 14 CCR§ 18459.3-Retention of Comprehensive 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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 10 In Compliance - No Violations <br /> 0 0 Other: § —_ _ <br /> Comments <br /> Inspection Form Included: 0 L <br /> Comments Included: ® - - -- - - ---���— <br /> Business Rep's Signature Phone Number s s gn ure Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "v o/ A P f ! 2 3 <br /> ■ White - - - - -- ® ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Cop LE <br />