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�'J+7� O1It!`4Vf OCJ <br /> gEBB <br /> : <br /> Waste Tire SAey & Inspection Report Inspection Report Number <br /> 816H� State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1086990 <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 131 -7 15 169 - Inspection Type (Fill one)Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c�11 JQQ r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> I Physical AdS�die v� a,�r y ��S I � � - 1 0 l r <br /> �J �J`��lVtrt� <br /> 11 <br /> 25,C67co c'U'Qr— Kd , <br /> Street4cc, (2A q5;,pC) Inspection Date <br /> , <br /> City State ZIP Code Time In Time Out <br /> Business ep Title / ® AM / I ® AM <br /> ��� J� ` 0� • I -- <br /> 1. PM / ` I I O PM <br /> -- - — -' Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) l5 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ; � � � <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> I O Q Closed Q Altered <br /> GPS Latitude • ' Q Hauler Q Indoor <br /> .__0 ® Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <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 /> 0 Service Station Q Hauler ® Agriculture Q Shredder Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STgTUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation <br /> Q Extension <br /> 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 <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 EX7) <br /> Q O 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 Referretl/C-IWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 7 z- <br /> lc� A—t,-PJ14 0v� MAd 81 <br /> a-rc a <br /> Inspection Form Included: Q <br /> y� �� <br /> - <br /> Comments Included: Q --- <br /> Business Rep s ture Phone Number Inspector's gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: Incorrect: f X .� M P 12 3 <br /> White Copy: IW Yellow Copy:Operator Pink Copy:.LEA <br />