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Waste Tire Su%y & Inspection Report, nspection Report Number <br /> �10a State of CaliforniaCIWMB <br /> ew 04104) <br /> California Integral d'81 WastJe Management Board Survey Form - Page 1 1 T 1 1 1140856 <br /> PartA- Survey_ __ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details -� <br /> TPID- 0 ' Inspection Type (Fill one) <br /> 2 <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /, If Referral,choose referral type(Fill one) <br /> Identifier: Ccs,,,►_' ��j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J_ Inspected By Inspector <br /> FR ,s l�,�, �� of L-d; p <br /> Physical Address - J 0 <br /> �T7'✓1cL4'2 C'CC-"l ��itl�,a�.. <br /> Inspection Date <br /> La ; LA gs2Lto <br /> Time In Time Out <br /> Business Rep Title y (� _ <br /> 11 ( / , O PM �, ( ® PM <br /> Llro'c_-_Q_Ccc _w,.Cw� _ _ �nk - - - - - - --- - <br /> — --- �— _ Operational Status] Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ®Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 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 /> --—.- <br /> ryV I 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 <br /> O 0 § ' QP In Compliance - No Violations - <br /> Other: <br /> Comments <br /> tlbc.if"YYLZ !mpe Aiz`con, on ![tet j� G�.lp[�t Com•, zw 7zt.e� <br /> ,Inspection Form Included: <br /> Comments Included: <br /> s VKCorrect: <br /> ep's Signature Phone Num r nspector's Signature Phone Number <br /> INSTRUCTIONS ON BA Incorrect: r ` 1171-41 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink CV.p L A <br />