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Waste Tire SAey & Inspection Repor _ Inspection Report Number <br /> �� CIWMB 81'(New 04104) Survey Form Page 1 I 1 - 1088220 <br /> California Integrated Waste Management Board Y - g <br /> PartA-Survey____- _ -_-_ _ - _ �__-_--- -- BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- ^� Inspection Type (Fill one) <br /> Site Suffix: 7 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> T <br /> Identifier: SA"i ✓ vk tJl�.i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> �— <br /> lowl bA,iiGISf ioPei 3 c - 1 © 0 <br /> Physical Address IIA�� f <br /> 22r o Co uti,w y Gub 61 Jd <br /> Stac_ » ���� Inspection Date O S 2 2 / 8 <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> O PM QPM <br /> �� � w wl;�� !e� <br /> -- - FN`r - CJ—�-- i Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) / �/'t D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L9 <br /> (Q 0 Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed Altered <br /> GPS Latitude 0 Hauler I 0 Indoor <br /> O 0 Inactive Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use Container <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 Other �� C <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 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 / 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 1 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 Referred i 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 0 In Compliance - No Violations <br /> 0 0 'Other: § <br /> Comments 29 2'0 <br /> -- �_r —�.�-�>r_ ��•►��- -- 2222 _ � T,,.� <br /> /vd. <br /> Inspection Form Included- OI <br /> Comments Included: Di - - 1�� •J�a --- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> --- - — <br /> --- - - - 62081 <br /> X <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V E X A* P L E 1112 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />