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Waste Tire Su. ,rey & Inspection Report Inspection Report Number ■ <br /> _= State B CaliforniaCIWIl - 1140606 <br /> 181( ew 04104) <br /> californiaintegrated nWasteManagementBoard Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q r O I Inspection Type (Fill one) <br /> Site Suffix: o Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: IW,uvl <br /> n�d L(,1 j� .(� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> F y � TLIA6 <br /> Physical Address 3 q ' n ��CvD <br /> Inspection Date / <br /> 5� o On C gS�uS 10 C� 0 <br /> Time In Time Out <br /> Business Rep TitleO AM 0 Q AM <br /> ` O 0 PM 3 O �/ ® PM <br /> �ra�l� Sp, ol_o OU�o��' <br /> - --- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 Q o (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4§ Active i Passenger 0 Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned i ® OTR O 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1ENFORCEMENT STATUS <br /> -_ - --- <br /> V I A HAULING AND-10-ANIFEST 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 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> 1 w_ � <br /> Comments �nt 4I ERCA ' Q. n�i�rl (AXAV ! — h, (4,nd-- <br /> \i Inspection Form Included: Q <br /> Comments Included: _, /rt --l��-. ��- ' (• . `ly' LJYV CD J-I�Vy�� O <br /> Busi� 's Rep's Sig atur Phone Number Insp�o,s turAe Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E A �_ I f 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:L <br />