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® „ Waste Tire S. ey & Inspection Repo. Inspection Report Number ■ <br /> State B California I 1 - 1127706 <br /> ew 04104) <br /> California IntegraM d Was181 tle Management Board Survey Form - Page 1 <br /> Part A- Survey - - BLUE OR BLACK INK PEN <br /> 1Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' (� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localn /, f If Referral,choose referral type(Fill one) <br /> Identifier: -�L�l� ,✓ L(�l I C/J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name \ Inspected By Inspector <br /> Physical A <br /> 3 9 C � ,2n}j C � v✓1 <br /> re6' I <br /> Inspection Date r ) !l <br /> Time In Time Out 6 CJ <br /> Bnussiness Re(p�eierTitle O AM 0 AM <br /> a PM PM <br /> cuA --- -- — - ----- Operational Status Tire Type Business Role IStorage <br /> Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active ® Passenger 40 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ®Indoor <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> — - - --- <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT 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 / / m <br /> 0 ! 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 1 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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments - <br /> F(�-G G jIm Gyc k.j - <br /> �j <br /> Gy Ao_oa-,_� ic,�- <br /> Inspection Form Included: 01 <br /> Comments Included: 0 -^� Ql'370 -- <br /> - - - Business Rep's Signature Phone Number Iris or' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect y� I E X A Z 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink COW <br /> A ® ■ <br />