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® Waste Tire Su. - ay & Inspection Report Inspection Report Number <br /> i" CIWMB 8111(New 04/04)fornia 11 - 1143535 <br /> California Integrated Waste Management Board Survey Form — Page 1 <br /> Part A- Survey _ . BLUE OR BLACK INK PEN <br /> Business Profile In Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: y lJ Routine Q Re-inspection Q Referral Q Observation <br /> Local I r If Referral,choose referral type(Fill one) <br /> Identifier: �(,�o J oe,ltf n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - -- _— - <br /> Business or Facility Name t <br /> Inspected By Inspector <br /> �s��s�Ag- �al�- � Court f Chu 3 � - 1 o I <br /> Physical Address Vin CSZao <br /> ��3t �Tod12S,� �a <br /> Inspection Date 7 Q <br /> Time In Time Out <br /> Business Rep Title I t O AM Q + PM <br /> PM I <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' 5 cl (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' A Active Q Passenger ®Generator • Outdoor <br /> 0 Q Closed Q Altered � <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 o Other C-404 Cbtisk <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 /> 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> I <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments l��— 1� 2�� fTOi MzAp. 1S �WCL <br /> 7 <br /> _._ <br /> Inspection Form Included: ® Q107 �) 1 q�v—��?Comments Included: l C I S <br /> Bu ness Rep's Signature Phone Number Inspecer'sSignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: I 62081 <br /> X � AM e �: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE ■ <br />