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`= Waste Tire Su*y & Inspection Report Inspection Report Number <br /> %� °•'�. State of California <br /> CIWMB grated 1 teManage) Survey Form - Page 1 I1 - 1141151 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - y. <br /> Inspection <br /> / € <br /> p Type (Fill one) <br /> Site Suffix: � <br /> inspection Q <br /> Referral Q ObservationQ Routine Q Re <br /> Local . _ If Referral,choose referral type(Fill one) <br /> QCHP QCIWMB QCom Complaint Q Educational Visit Q OtherIdentifier. � <br /> Business or Facility Name Inspected B <br /> �1p Y Inspector <br /> Ph sicaI Addres <br /> rL 1 L <br /> Inspection Date '..._._ ! / ; i F <br /> 7) cj <br /> � <br /> S#afe ,i f>��Ode Time In Time Out <br /> Business Rep Title ' � _� � O � . �',�.. ........ O PM <br /> AM <br /> � • <br /> O PM <br /> Operational Status�t.l kms � 1G11..� ....._...... <br /> p Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (i ill.all that ppiy) <br /> re Count ==7 <br /> Active Passel er Generator) Q Q �.9 ' Q Q Outdoor <br /> G PS Latitude 10 1 Q Closed Q Altered <br /> •i ���� � Q Hauler 0 indoor <br /> € . . O Q Inactive Q Truck <br /> Longitude — I I Q Planned 00 Q End-Use 0 Container <br /> ,. <br /> Business Type (r=ill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 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 HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> --- Q Notice Of Violation Q Extension <br /> Q O 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 I I I O Ell <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB I I <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 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 /> Q In Compliance - No Violations <br /> QQ Other: § <br /> Comments <br /> iFL i'>j nC (_�? - <br /> �-mac. <br /> Inspection Form Included: Q <br /> tatramenis incittt9+.:d: 0 <br /> Business Rep's Signature Phone Number Inspector's Sig l_)Wre Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X X j A62081 <br /> l � � � �� <br /> ■ _ _ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />