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■ _. Waste Tire Su. ,ey & Inspection Repor', Inspection Report Number ■ <br /> State CIWMB California I 1ew 04/04) - 114 3 8 41 <br /> California Int grat Integ81 rated Management Board Survey Form - Page 1 <br /> Part A-Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 3 6 0 L 0 Routine 0 Re-inspection O Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier. sck'n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> o 1 10, 4r?, Pots 1�&o<-c <br /> Lc-,Ah, 6, q_5-330 Inspection Date � 1 <br /> `� Time In Time Out C <br /> Business Rep Title `` O AM O AM <br /> ' l7CJ �vl PM 0 PM <br /> 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 /> r 0 Active 0 Passenger 0 Generator O Outdoor <br /> Latitude O 0 Closed 0 Altered <br /> GPS O Hauler 0 Indoor <br /> O 0 Inactive O Truck <br /> Longitude — 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair ®Trucking Fleet O Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body O Car Dealer 0 Collection 0 Crumb Rubber <br /> O Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <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/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 1 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 ®In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> �tl/o;7t e i�yfF� Jjsi/ YG//�/IIYc�� O-A A �'a l L IYI� &/ky'- <br /> i/`�' - <br /> AID <br /> _�_� 1�CS fax! <br /> cz <br /> Inspection Form Included: <br /> Comments Included: - `^�l'_b '�" <br /> Business R p's Signa Phone Numbers n e s u_re_ Phone Number <br /> INSTRUCTIONS ON BACK Correct. - Incorrect: M Z 62081 <br /> ■ - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink op EA <br />