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i a Waste Tire Survey & Inspection Report Inspection Report Number . <br /> State of California <br /> CIWMB1811(New <br /> Mana a) Survey Form - Page 1 11 1140782 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ - BLUE OR BLACKIN_K PEN <br /> Business Profile Inspection Details <br /> TPID- _ � I Inspection Type (Fill one) <br /> Site suffix: 1•� t� Routine Q Re-inspection Q Referral Q Observation <br /> Local \ If Referral,choose referral type(Fill one) <br /> Identifier: S Ctn J O 1,(,I711 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ta <br /> Physica6e+, ��. 3 - 1 0 n E <br /> l Address 1 s b <br /> Inspection Date J /� D <br /> tJLQ'�l1 J Time In Time Out <br /> Business Rep Title i W AM 10 AM <br /> 1 (D Q PM l �J O PM <br /> 1 e 1�12e. ern►�t-c <br /> pC,�<, — ---- 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 /> Q Active Q Passenger Q Gen rator Q Outdoor <br /> - - --_ — 0 IS Closed Q Alter d h � "�� I ■�� <br /> GPS Latitude J Q Hauler Q Indoor <br /> O Q Inactive Q Truc � <br /> Longitude - Q Planned Q OTR 0 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 ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V-1 A HAULING AND MANIFEST REQUIREMENTS <br /> 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <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 EXT) <br /> 0 0 - - ---_ <br /> 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> w5 <br /> No v1'o1zq,V1bT <br /> - <br /> I s CUf) <br /> Inspection Form Included: QI ' <br /> 2nclNumber <br /> �-317F <br /> Comments Included: - - - - - -BusinessRe s ignatur Phone Number nspec ' natu <br /> INSTRUCTIONS ON BACK Correct: Incorrect X 131 <br /> 62081 <br /> A Pz <br /> White Copy:CIWMB Yellow Copy:Operator Pink Lp <br />