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Waste Tire Suapy & Inspection Repor nspection Report Number ■ <br /> ka <br /> CIWMB 81California <br /> (New 04104) Survey Form - Page 1 I 1 - 1140737 <br /> California Integrated Waste Management Board <br /> Part_A_Survey -_ _ ---- __- --- - _ _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: O (3 G 2 & 1 Q Is Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s .A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> K11 =,nTc,-at, I;;re- and UAJ . <br /> Physical Address �aCTC <br /> 13 0 3 S . C)"Y-0 V,re- Lam _ --- - -- <br /> L o d; zr_ CA Q S Z.y O Inspection Date O $ / Z / 0 <br /> r <br /> Time In Time Out <br /> Business Rep Title C) ` Q AM "� Q AM <br /> / 8r PM 4 0 ® PM <br /> Cjc rv�c.. <br /> c-- <br /> Operational <br /> - - <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 /> 0 Q Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station ® 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 Q 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 I 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date FTI / 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments L, <br /> —X0.5 �h'IC� ViCJ�[. f,0Y--S — <br /> P�( <br /> C.—I y-Cc 9 1 a L4 (azC'16� -4YL sy cw t-t .OYE W,C. - <br /> c�,ccr.Q.o,rs <br /> Inspection Form Included: QL <br /> Comments Included: (�LV�1� �L�-�` z <br /> 0 Business Rep's Si ture Phone Number �1_n,pctr' Signa re Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. � �/i ) p� r� t 62081 <br /> ■ _ _ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: E <br />