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EII- <br /> Waste Tire SurV & Inspection Report inspection Report Number <br /> 11� fornia <br /> CIWMB 81State of 1(New04/04) Survey Form - Page 1 11 1088037 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i t4 <br /> O n r7O I Inspection Type (Fill one) <br /> Site Suffix: y 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localr- If Referral,choose referral type(Fill one) <br /> Identifier: ((tnj Cc,un Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A Co <br /> Physical Address �Qf1 �S CD a <br /> (9,so 0(,A "a3 - - <br /> m)sInspection Date b G <br /> Time In Time Out I <br /> Business Rep Title V I 3 O <br /> AM OAM <br /> a PM � � � ® PM <br /> c 6t0c+0r\' v - <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r1 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> p� 0 Active Passenger 0 Generator ® Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive �Truck <br /> Longitude — O End-Use Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility : NRf ORCEMENT STATUS <br /> # •.w Notice Of Violation 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. <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / <br /> 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m <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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred iWMB Enforcemeri <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ---------- <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O S in Compliance No Violations <br /> O O Other: § _;.. <br /> Comments 1 1 <br /> o ��� �bn- A0 Ac on <br /> �-Li 465' ma4cS+ woo. A\Vt:n L1001v"UG�4r& Crlm,O e,t� �11���_���Sef Vc-� <br /> 15 0 C S'v � Lm (LA i 61 <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />