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Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> 517 State of California <br /> CIWMB tBt( eSurvey Form - Page 1 11 - 1088462 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 3 O ' 0 4 Routine Q Re-inspection Q Referral Q Observation <br /> Local r ' 1 1 If Referral,choose referral type(Fill one) <br /> Identifier: sup J[�fi G�(t tl ��,G,�'{1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name '1"�_11 ( - Inspected By Inspector <br /> Physical Address 3 I — I 0W 1'Es 6 <br /> L� <br /> Inspection Date 5 1 �l 0 5 <br /> Time In Time Out <br /> Business Rep 11 Title {� 1 S AM i O AM <br /> - f,, nw 1 f tQT. 11 J 0 PM 1 0 0 PM <br /> J Operational Status Tire 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 /> is Active Q Passenger 4D Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude - Q Hauler Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 <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 /> 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 Date m / / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2 1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV orE)M <br /> Q O 14 CCR§18459.3-Retention of Comprehensive 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 10 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> Other <br /> Comments r1 J� �� V ����\5 +e ��� V �Owl n +�`iJ n fr <br /> -- <br /> �oMd CA�1&rS or WQ_ s . <br /> hUA41�°lot l�S own uy,AAC IIrtS,40 l,�'�sCorQV��� <br /> Inspection Form Included: Q <br /> Comments Included: Q` `�� �CU ��r� 77G��Z3 � a0q <br /> Y--,W <br /> Busikes5 Rep's Signature Phone Number Inspe is Signature4 hone Number <br /> INSTRUCTIONS ON BACK Co ect: Incorrect:X �,. E.X A M P LEI 1 2 3 62081 <br /> White Cop..CIW - Yellow Copy Operator Pink Copy:LEA <br />