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Waste Tire Sur y & Inspection Report ispection Report Number <br /> State of California <br /> WE <br /> a T 1 — k <br /> California ICWMB 04/04) <br /> ne grat dt81 Was eeManagement Board Survey Form - Page 1 I y 1140616 <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � 2 � _ 6 � 'Inspection Type (Fill one) <br /> Site Suffix: %j ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �GvV� f� C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �CIOLA-t .�rcuttPo-cwt U'^� <br /> Physical Address <br /> Hyl <br /> Inspection Date f Q f <br /> rS c lGi-+�r— CA <br /> Time In Time Out <br /> Business Rep Title � AM Q S ® AM <br /> 01 3 O / Q 0 P ! 0 P M <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) f f / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (� S Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> D Q Inactive 9 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> eeAuto Repair Trucking Fleet Q Q Dismantler Q Tire Derived Fuel New TiDer <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _ _...- —_.. ._............ _ _ _ <br /> VIA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> ---- - <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q i 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 /> 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 <br /> 0 i Compliance No Violations <br /> Q Q Other: § <br /> Comments <br /> – K0_V _VXA_-- )),-L& s -fir—_ 4-w-s ��+o-e, <br /> -- <br /> Inspection Form Included: Q� <br /> Comments Included: ® - - -- — -- - <br /> Busines ep Si a ure one Number spector's Signa ure Phone Number <br /> INSTRUCTIONS ON BACK Cori <br /> e' et ttGorre+ t.� A g 1 233 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink ColLe <br />