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Waste Tire Su ey & Inspection Repo"Inspection Report Number ■ <br /> CIWMBState California I 1 - 114 0 7 4 9 <br /> 1 04104) <br /> CaliforniaIntegrated WaseeManagementBoard Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � " � C - O � Inspection Type (Fill one) <br /> Site Suffix: lJ� 7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: 5 J661 41/r) �f�(,, (lk Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busin((e��ss or Facility Name Inspected By Inspector <br /> \�6ALkAIVA t., Tlfc.,'� _ <br /> Physical Address 3 9 I v(� <br /> Inspection Date_5 <br /> I <br /> Time In Time Out <br /> Business Rep 1 Title O AM O AM <br /> [y)L-S l�.. A civ C 1 ti O PM O PM <br /> ---- ---- - — Operational Status Tire Type Business Role Storage Type <br /> ,�yl <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> /y"J <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered � 'Yn� iNl <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck"/A <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> il® New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 j ENFORCEMENT STATUS <br /> ! V A HAULING AND MANIFEST REQUIREMENTS <br /> Q <br /> Q 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / 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 I <br /> Z04, <br /> t <br /> V1o on r 1 '1 <br /> Nt �u i sS i Aconjalb T q 0>S6. <br /> Inspection Form Included: Q <br /> Comments Included: <br /> N�"1�-�' -� �� - <br /> us ness Rep's Signature Phone Number _Ins or's Signature Phone Number <br /> INSTRUCTIONS ON BACK [�Correc .ql Incorrect X 'f" '\'/ )CIA MIPI LJEJ 1112 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />