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Inspection Report Number <br /> Waste Tire Su. .ey & Inspection Report ■ <br /> CIWMB1 t'fornia <br /> (New04104) Survey Form - Page 1 I 1 - 10 7 9 41 4 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- t Inspection Type (Fill one) <br /> Site Suffix: q 3 cl 5 -1 � l ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalCC ^(.., If Referral,choose referral type(Fill one) <br /> S <br /> Identifier: A ��Ockqj `"\ Ccun�zi 0 CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 91 0 Avkv cey'\A�ir <br /> � <br /> p � q �4� <br /> � 1 Inspection Date <br /> `v�� `j' "'�—� Time In t Time Out <br /> Business Rep Title _ _ O AM O AM <br /> JC.CJ'CT �I G� �P.i 7 LCT� V"C"S _5 `•.> 0 <br /> PM C72 G -5 QV PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 3 <br /> ®Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — End-Use .Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 9 Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler 0 Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Lip In Compliance - No Violations <br /> O 0 Other: § <br /> Comments <br /> ,Inspection Form �nc <br /> ncluded: O <br /> Comments luded: <br /> Business Reps Signature Phone Number Ins e o's Aiabture.,o Phone Number <br /> — � ! 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: '^ ( j �/I AL hll 1112 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:tEdl ® ■ <br />