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r, Waste Tire Sur y & Inspection Repinspection Report Number <br /> State CIWMB California Y g I 1 - 114 3 9 6 4 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: J j 0 Routine 10 Re-inspection 0 Referral C) Observation <br /> Local r' If Referral,choose referral type(Fill one) <br /> Identifier: 5(A J 4)C& lU1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address J 3 01 Ben Es ah) <br /> t(no S. <br /> Si) C�Ao� A ��^, Inspection Date 5 r1 I <br /> H rJf"1-jam Time In Time Out <br /> Business Rep Title 3 3 o OAM 0 PM LA 0 AM <br /> rov � 0 � PM <br /> Der --- ------- - -- <br /> - - -- - - -- ----- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger • Generator • Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Is Truck <br /> Longitude - 0 Planned • OTR 0 End-Use 4 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair • 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 /> j V j A HAULING AND MANIFEST REQUIREMENTS 0 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 <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 /> 0 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 _ , 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 Q 1 Other: § <br /> Comme <br /> ---Its <br /> 5e-c.�Qr� re-7 1 n<1N,(I'n eS-Fusrylm-s o a �1i s a c. v,'vu ��. <br /> �r n5pu, cin c v n rzr- <br /> 51-7 Iy, Gl{111 l_�lt� 0�11)tn�►n� We IS (�U Ca ; <br /> -- <br /> Inspection Form Included L{ Z f-L( 1 S ' <br /> 4� <br /> Comments Included: - - --- �-- - <br /> fat 317 g <br /> U rti Phone Number Insp or's Signature Phone Number <br /> - -- - - — _ <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect �/ 1JE C A s L I <br /> _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y: E <br />