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,3 I Waste Tire Sur 'Y p& Inspection Rep ort Inspection Report-Number <br /> State of California <br /> CIWMBIBY(New04/04) Survey Form - Page 1 4 - 0 0 <br /> �•+ California Integrated Waste Management Board <br /> w 668 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />{ TPID- O ' Inspection Type (Fill one) <br /> Site Suffix: / 0 Routine Q Re-inspection Q Referral O Observation <br /> Local } If Referral,choose referral type(Fill one) <br /> Identifier: Sof,-, (1�,(r'� � ���tL ' { Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i j - -- I <br /> Inspected By Inspector <br /> L -Ro Ids (Aro 1 r <br /> Physical Address' <br /> Ste } I _ _ <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> / f`I MI ' O 5 PM �[H�] ' 0 PM <br /> �2 l'1 Yl(�`l �'� f_ YC.t tA.)1 D��t ,, b(.�i`rE� � --- ---- <br /> �T�} Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) D f r l I I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J �•JJ (0 Active Passenger (0 Generator � Outdoor <br /> O . Q Closed 0 Altered <br /> GPS Latitude m . O Hauler 0 Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet O Government 0 Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body Q Car Dealer o Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O.Agriculture Q Shredder (5 Other 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - <br /> Q Q PR(3t§'42951.-;--Waste,Tire,Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> I0 Q PRC§42953-Contracts with Registered Waste`fire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle - <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> O 0 14 CCR§18459.1 (a)(b)(c)-.Tire Program ID Number from CIWMB <br /> . M /O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7). <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q O Other: § <br /> Comments <br /> t_ M1 c1U-�f L !✓�` c f`��i ��it <br /> hC( ci , (�btG{ ' (titJ 1��►�Jl�it' UJC� �!C?�'t(1 . 1 <br /> � reopyk_'1,( C'ko( k(a_pd f��lr\r;y 4�1(p. AS (GS119 �f S 61-1 <br /> _(41 �J(, p d V-00 � hail Irv- Iia a i I ro Tfe on r t..) f )5 0 <br /> �VJ49d Upon m s l 41re v t- b re 0©u S 0_W_r�e r.� . _� l r(, <br /> nspection Form Included: ill' <br /> Comments Included: _. <br /> Business Rep's Signature Phone Number Inspector's Signature _ Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �. i� Eta A'M P L 1111 <br /> 1 R 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />