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Waste Tire Su. ijey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB1811(New04/04) Survey Form - Page 1 Il - 1143763 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � I LA - Q � Inspection Type (Fill one) <br /> Site Suffix: ( (0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: ISC40 J 1.t.1�1 � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ne�� �run5�o � �c)n _ l <br /> Physical Address 3 <br /> a�rl v c4,4(A- <br /> Tjr <br /> <' Inspection Date � � o (1 <br /> "� ��� Time In Time Out �`// <br /> Business Rep Title 0 AM0 AM <br /> ' 1 ° 3 " * PM 0 0 B PM <br /> J� U)n%crC�ral nz„� Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ° ® Active 0 Passenger 0 Generator 0 Outdoor <br /> PS <br /> Latitude O 0 Closed 0 Altered N14 <br /> C70 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 /> Vi-FA-] HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M m m <br /> 0 O 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 /> 0 O 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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ) fS jjjf-e. 44 Onntll <br /> Pp V'i AH0-M &11- I!J14e,� 17 o n Q <br /> -t l <br /> FG�U r �i 04, l <br /> Inspection Form Included: 0 G a <br /> Comments Included: 0*ne — lill, A - � `'�—'L - <br /> _ _ eps Si ture Phone Number Insp or's Signat Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: I A' E X A 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: ® ■ <br />