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Waste Tire Survey & Inspection Repo L Inspection Report Number ■ <br /> California <br /> (New 04/04) Survey Form - Page 1 I 1 - 1141034 <br /> CIWMB 181 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey -__ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SGn J "LL,r. G IAT lQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CCci, kal ��,mb�� CD_ <br /> Physical Addr ss <br /> 0`1 Cfom W ctt Ave,. <br /> eo v��b� �� ��� Inspection Date � � 1 5 � I D <br /> S <br /> Time In Time Out <br /> Business Rep Title O� AM 11 O AM 1♦ PM �1 5 0 PM <br /> -- - - - -- - - 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 /> f Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered NIA NIA <br /> GPS Latitude i1 Q Inactive Q TrucQ Hauler Q Indoor <br /> O �t`t <br /> Longitude - Q Planned Q OTR Q End Use - Q Container <br /> -- - - <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 L <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -V I- AIHAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <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 Datem / m <br /> Q. Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> 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 S in Compliance - No Violations <br /> Q Q Other: § <br /> Comments I?fm L11 <br /> ,( �),� _ �„r 011 �b,�,. �•1.t S C�cN `� �� ' <br /> It (X <br /> Inspection <br /> ts QQ - -- - - - - + 64MAt-3k <br /> CommnIncluded: <br /> Rep's Signature Phone Number �Inspec 'sSignature ; <br /> PPrdne Number <br /> INSTRUCTIONS ON BACK j Correct. Incorrect X -1 A dIw f ' � 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LE <br />