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Waste Tire Su ey & Inspection Report Inspection Report Number <br /> State of California <br /> C1WMB (New04104) Survey Fora � Page 1 1 3 , 1 0 2 5 7 5 8 <br /> California Integrated Wade Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � � _ � � {nspection Type (Fill one) <br /> Site Suffix: f/ Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fitt one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> �'t cs,✓�In�� NtQ�►'� ' Inspected By Inspector <br /> Physlcauddress <br /> Inspection Date <br /> Time In Time Out <br /> Busi ss Rep Title I 0 AM 0 AM <br /> 0 PM 0 PM <br /> RrV f•�Lxr S�i?r,� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply), (Fill a))that apply) ' (Fill all that apply) <br /> t f S Active Q Passenger 0 Generator Q Outdoor <br /> GPS Latitude <br /> D I Q Closed Q Altered <br /> I Q Hauler Q Indoor <br /> a Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> I I <br /> Business Type (FIJI all that apply) <br /> O New Tire Dealer Q Auto Repair 9 Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> iQ 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 /> HAULING AND MANIFEST REQUIREMENTS 0 Notice Of violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 00 <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 114 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / I I I ' m <br /> O Q 1 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> OI Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I GI;NMB Enforcement <br /> Q 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ....... --....,_ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators t <br /> Q Inopilance.. No Violations <br /> 0 Other: § _......._...... <br /> Comments <br /> \N10t c.- 7/I� <br /> S,�c. d�era�e� SGL✓ vwnc✓- f1c,�.✓�J�tsi��' rtw�-,�. <br /> •��f �,� � 5 a-� local h - <br /> Inspection Form Included: OT�Comments Included. : � f� O 768 <br /> Business Rep's Signature Phone Number o ' Ignature Phone Number <br /> 1 INSTRUCTIONS ON BACK Correct: Incorrect; �,`�• ./ A M t��Iw � �1��� 62081 <br /> White Copy:CIWMB i s; -opy:0peratut Pink Copy.LEA ® ■ <br />