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Y f <br /> Z =, Waste Tire Sul, .1y & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 04104) <br /> I 1 Z 14 0 6 3 0 <br /> California Int grat d'WaseeManagementBoard Survey Form - Page 1 <br /> P--t A- Survey_ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> „ Ip. � � � � � � � - � � Inspection Type (Fill one <br /> Site Suffix: O <br /> Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S JOct 4 al I\ cou t/\ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 r Inspected By Inspector <br /> Tmsn 1p1Ste- If- Fm0rgLupiU" 3 t - <br /> Physical dress 1 CSCvIJ� <br /> aLM 'iloe-i ny �Nal <br /> C� Inspection Date y � � a J_ � � f� <br /> � ����o c �a n I �J <br /> Time In Time Out <br /> Business Rep Title o 0 AM I 0 AM <br /> I S PM 3 ® PM <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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude D 0 Closed 0 Altered NIA 'V14 <br /> GPS f0JA 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Vew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> L <br /> Jsed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 <br /> M / 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 O - -- - - - <br /> 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> -*-fn Compliance - No-Viofations <br /> 0 0 Other: § <br /> Comments 1��1 - 1-fit — - �0-r�_�/1_C1A�fS_V__4� �61:,5 <br /> NO <br /> .,ection Form Included: 0 <br /> Comments Included: 0 -- ------ -- - -jin ' — - UA k6� d <br /> _ _Business Rep's Signature_ Phone Number specINSTRUCTIONS ON BACK Correct:* Incorrect + ViX A11213162081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />