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" oszo� o�voso <br /> == Waste Tire. Survey & Inspection Report Inspection Report Number <br /> nee. <br /> 90 State of California. <br /> CIWMa 187(New 04/04) <br /> Survey Form - Page 1 I1 - 1086927 <br /> Callfomla Integrated Waste Management Board <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: t3l 1 Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � _ v � _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Address <br /> a67_70_0 <br /> S <br /> Street P_�c�v� _R��, �- <br /> t Inspection Date <br /> �" 'y �J�� � Time In Time Out <br /> City l Siata ZIP Code <br /> Business Rep Title O AM —� , j--_� Q AM <br /> ' ��&PM L I O J of ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /y (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPSLatitude <br /> Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 I I <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULINGAND MANIFEST REQUIREMENTS 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 Requirements Date <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 EX7) <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/C-IWMB 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 ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> 5 a yr a _�- 2 c dr �� a� 4!�Wre_x <br /> Inspection FormIncluded: Q <br /> Comments Included: Q <br /> Bus ss ep ure Phone Number Inspec 1's Si atu a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C t rrect incorrect: E X A MA P .L E 1 Z 3 <br /> White Cop :CIW B Yellow Copy:Operator Pink Copy:LEA ®. <br />