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' Inspection Report Number <br /> Waste Tire SL.. vey & Inspection Repoi _ <br /> CN AMB 811ifornia <br /> (New04/04) Survey Form - Paige 1 I 1 - 1143785 <br /> California Integrated Waste Management Board ! �. <br /> Part A- Survey-__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _7 inspection Type (Fill one) <br /> Site Suffix: ' (� ` Q l 49 Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: l)(� aCo'g Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l` Inspected By Inspector <br /> �lk,5 k47r �aUs l i <br /> Physical Address <br /> rl- <br /> / \ �� 3 <br /> ��� Inspection Date <br /> Time In CX Time Outl <br /> Business Rep Title Ar O AM <br /> ® M <br /> V /� 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 /> M ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR i Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer `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 Q <br /> HAULING AND MANIFEST REQUIREMENTS j <br /> 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 / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § <br /> Comments kov <br /> *Me' C'W"Q'0_C 7Tr1 <br /> CJ- <br /> 0C <br /> Inspection Form Included: Q ZC Comments Included: Q *_�'Pws <br /> Bus n _Rep's Signa urePhone Phone Number 7ignature Number <br /> INSTRUCTIONS ON BACK Corr Incorrect: ��FE'XfVMKL E y 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :LE <br />