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Q$4�5�440�� <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> re Stale of California Survey.Form - Page 1 13 - 1 0 7 3 4 .1 0 <br /> CIWM13181(N-04104) <br /> Califomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- f.} O / Inspection Type (Fill one)" <br /> Site Suffix: ff 1 ( 7 0 — I$Routine Q Re-inspection Q Referral Q Observation. <br /> Local ♦�'^ If Referral,choose referral type(Fill one) <br /> Identifier: ./�" Q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> re� J C I Inspect(e�d 8y Inspector <br /> A' 6,( <br /> r� <br /> Physical Address -I Fi o7( L( /,eVt"4_ �3t- <br /> I ?, Do (j. ATI lJ <br /> Street <br /> ��n C a v 1 q`�j j 3! I Inspection Data <br /> City C State! ZIP Code Time In Time Out U <br /> O PM <br /> Business Rep lTitle�� ^' p O AM O AM <br /> I lob San�Yll/� --JL_Is�� "'' "tel O PM 'm <br /> -- Operational Status Tire Type' •Business Role -Storage Type <br /> ! I j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) Tai <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude . . Q Hauler Q Indoor <br /> 0 ®Inactive Q Truck <br /> Longitude —. , Q Planned Q OTR -Use Q Container <br /> Q End <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 /> Q 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 I I <br /> Part B-Inspection of Waste Tire Dealer,,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND•MANIFESTREQUIRE.MENTS' Q Notice Of Violation Q Extension <br /> Q Q 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 Data m / m /m <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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> ----------------- ---- <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB 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 1 Q 1 Other: § <br /> Comments l �L`y'L • t�K �oPS K�f MQ1�1 V[e_ `�1N2 <br /> ✓i ces e �4l( f%re Sefruia d.onQ 66F 5iit--e of 66AC0 Ir"_ <br /> A/o ✓oo fv <br /> Inspection Form. Included:Q <br /> Comments Included:Q <br /> Business Rep' Ignature Phone Number Inspector's Sigoffure Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:X(% V e X A M f 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> L <br />