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Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> i11 State of California <br /> CIWMB 181steManage) Survey Form - Page 1 I1 1088083 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection O Inspection Type (Fill one) <br /> Site Suffix: �3 3 \Q • Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf <br /> 1� If Referral,choose referral type(Fill one) <br /> Identifier: sun J1 n J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (�/� <br /> A�l d- Sons W t 1 Inspected By Inspector <br /> r «c on 3 1 13�n Esc <br /> Physical Ad ess <br /> GrLYPI C4, r <br /> Inspection Date 5 � / O <br /> Time In Time Out <br /> Business Rep J� Title G� O AMQ AM <br /> ® PM 3 � � 0 PM <br /> U 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 /> oil, ®Active ® Passenger 4* Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> D Q Inactive goTruck <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair A 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 ENFORCEMENT STATUS <br /> V . A HAULING AND MANIFEST REQUIREMENTS _ <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Q Extension <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 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 EXT) <br /> Q Q 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 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 /> Comments `1 1n5 ' � O`1 IS AlVv� I �V' <br /> b S are_&_s 0� wn , .1 <br /> � v ` �o <br /> USA ,fie- u e- SIL4 �O (mss UO�b In - � d� � �r 16S. <br /> Inspection Form Included: Q <br /> Comments Included: QG�u <br /> Business Rep's Signature Phone Number Inspeor's Signature Phone Number <br /> -- __ _T-- 62081 <br /> INSTRUCTIONS ON BACK Co Incorrect:X 1E X A M P L E 11 , 2 3 <br /> 1'Vhde Copy`CIW1`013 Yellow Copy Operator Pink Copy:LEA <br />