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Sao <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State (California <br /> C1WM Survey Form - Page 1 1 6 - 0 3 0 2 2 <br /> CIWMB 181 thew 04104) <br /> California Integrated Waste Management Board <br /> Part A-S <br /> ur <br /> vey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j7 5 3 8 O , Inspection Type (Fill one) <br /> Site Suffix: <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: —To Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �'l 0 Itil1?r Li -el-h 3 _ r� <br /> Physical Address ( V -T <br /> Ro4k 'Rd <br /> CA. /'a5- -5310 Inspection Date I / f C / C) <br /> l+7 i Time In / Time Out <br /> Business Rep Title O AM O AM <br /> p f( Q PM O PM <br /> J1r l <br /> Operational Status Tire Type Business Role <br /> p Storage Type <br /> O <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger Generator <br /> ® Q g ® Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck I <br /> Longitude Q Planned ®OTR Q End-Use Q Cont finer <br /> Business Type (Fill 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 <br /> _ QShredder Is Mali <br /> I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility hNFORCEMENT STATUS` <br /> frfllStULING AND MAFIiFEST F2fQU(Rc <br /> ° i � Q 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 RequirementsE Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 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 Compttance No Vtolattans <br /> Q Q Other: § _ <br /> Comments <br /> LL <br /> j fj <br /> c I.►O _ <br /> Inspection Form Included:O t - ( tR <br /> Comments Included:Q JI/W <br /> — rI" <br /> Business Rep's Sig ature Phone Number I oes i nature _ Phone Number <br /> INSTRUCTIONS ON BACK ( p 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 01:'.37.304.0091 <br />