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® Inspection Report Number <br /> Waste Tire SuRey & Inspection Report. <br /> 9 � State of CaliforniaC1WMB 04104) <br /> ■ <br /> California Int grat d181 Was eeManagement Board Survey Form - Page 1 T I. 1 - <br /> ­ 10881.37 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + Inspection Type (Fill one) <br /> Site <br /> Site Suffix: {L_ , Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I�`�1Cd►'I - SU G 9 U I n C.. 0 t„f nt4 I <br /> 1 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By <br /> Inspector <br /> Tran��or � , _ <br /> Physical.Addre_s_s_ _e <br /> 4 20W P► PLA_ St.� `.,u0 _ <br /> Street <br /> ! o <br /> Inspection Date t " <br /> L---. LO d11 -- ----- GA 9�ZttO <br /> C'ihl State ZIP Code Time In Time Out <br /> Business Rep Title . —� O PM o AM <br /> o Pm <br /> - - Operational Status Tire Type Business Role Storage Type <br /> The Count(Whole/PTE) I(Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> a ' 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latitude I 1 <br /> �---`.TTI ,`---��� 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> O <br /> Longitude - 7_1 1 0 Planned 0 OTR O End-Use O Container <br /> Business Type (Fill;all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q 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 /> V A HAULING AND MANIFEST REQUIREMENTS O 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 M / M / m <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 /> O 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 0 In Compliance - No Violations <br /> O O § _ <br /> Other: <br /> Comments <br /> o ( �.L <br /> ns I�.�c.-t I a n PA_r o r r'rX(j 1�ms (iqfie -tke �o 1_�.a w i n �w_t,; r A_(zd •: <br /> leo -���es s-t�red on Ife The nercl�Iol�S GY no lon5er � /9n-C,�-c�-cter _C <br /> +h►5 accak► an . Res-ammnd —to close 1 SC, Q I . Lo I_ ad <br /> i <br /> ter— — --- <br /> anspecfion Form included <br /> Ig, <br /> Comntnts Included: 0 _ zor�'�sS�ignature, <br /> �.A.. _ -, '.. - (� <br /> Business Reps Signature Phone Number In P Phone Number <br /> -- <br /> I : - -- ',,� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: dh�, I�' 12 ;3 a <br /> t White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA <br /> ■ <br /> i <br />