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Waste Tire Survey & Inspection Report Inspection Report Number <br /> 9i3 State of California T <br /> C,WMB 181 04104) <br /> California Integrated e <br /> Was eManagement Board Survey Form - Page 1 y 1143474 <br /> Part A-Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- �^ � Inspection Type (Fill one) <br /> Site Suffix: `V� / tJ 6 Routine Q Re-inspection Q Referral Q Observation <br /> Local c^ t If Referral,choose referral type(Fill one) <br /> Identifier: SU J u, Coup IO CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> (aJ A'" 0(0it, <br /> Physical Address <br /> A ���� Inspection Date <br /> 0 C/A <br /> Time In Time Out <br /> Business Rep Title S O AM O AM <br /> O i PM -I e PM <br /> - -- - - -- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J ®Active 0 Passenger 0 Generator Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude O Hauler Indoor 1 <br /> O Q Inactive Truck <br /> Longitude - IO Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that aPPIY) --- -- -- -- - - - - - -- - - <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler 10 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 O Agriculture Q Shredder ®Other "JUI <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date O / / m <br /> O 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q O (Other: § L10 <br /> Comments_&N- 17rl%-P -01) +41S J- --a n_ <br /> s sok -- --- <br /> Inspection Form Included: <br /> p O,/Ice _ - <br /> Comments Included: * - - /4______Phone__Number_ <br /> 5178 <br /> Business Rep's Signature Phone Number Inspe is Signat-- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X Ap �/ E X A Ott i - 1. 2 3i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.L ® ■ <br />