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KIMWaste Tire Survey &inspection Report Inspection Report Number <br /> Stata of Calffdmla ■ <br /> CIWMB 18t(Now aSurvey Form - Page 1 1 6 - 1 01 3 5 01 <br /> CaIIlomia Integrated Waste Manageage oament Brd <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business_Profile Inspection Details <br /> TPID- ' F0111 <br /> Inspection Type (Fill one)Site Suffix: jqj�j ®Routine 0 Re-Inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��M.�jC�(j{�� { 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other - <br /> Business or Facility Name si �e Inspected By Inspector <br /> (Physical Address ( � -1 ( I �`G�'t•t'�.L_ �`�_J <br /> 3V 0c) Wa", _� J <br /> Street <br /> I Inspection Date ! i� <br /> C;ty ( I J State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM 'm O PM <br /> .-- <br /> �A a.t- f►-ac <br /> I�tNIG2 � <br /> t—'� - -- -" ' -J Operational Status Tiro 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 /> 1 ®Active ®Passenger ®Generator i®Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude I 0 Hauler ®Indoor <br /> —,0 0 Inactive 0 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 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ®Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other L <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 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/Decalin Vehicle _n <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date[ I m / m <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required forNOV or EX!) <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 1 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 la in compliance - No Violations <br /> 0 0 Other: § <br /> Comments ► Sor ,_` � r liLl2s "o-W Tids t R90-Qnt>ryC <br /> �►V-. .�11`lS �0 tbx Sco,s lRl��DyAr a k1TN'P/,yw+ of 'f!►yt>? oF�i'19•ul'�U/�� P `� <br /> ui ;Y80 used -hetes s�,arke- L ,Y-04d t 4ad- f, t)S l kmt *P-s are sUd' _'a <br /> `k--b�'�Ck. and osLA'Y oid a s� -b k _ ara:-ect Id m W ire r <br /> inspection Form Included:0 �+'/,` 1l/_ � <br /> Comments Included:® '�J�M• �So <br /> Busines Bp's Signature Phone Number In pe tor' SIgnature Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct: Incorrect:zX( X A M P is 1 3 62081 <br /> ® ■ <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LFA <br />