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Waste Tire S._. ,ey & Inspection Repo, _ Inspection Report Number ■ <br /> CIWMB; Nw04104) Page 1 Il 1127907 <br /> California Integrated Waste Management Board Survey Form - <br /> Part A-Survey _-_ - - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: © 3 8 0 V 1 1* Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �Q�n � U\ t�j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addriss <br /> ,90-7th EI �C�Y�'•t�C� �f , <br /> Inspection Date <br /> � CA Rod l <br /> Time In Time Out <br /> Business Rep Title ' 0 AM j� 0 AM <br /> L l� © O PM <br /> 3 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 50 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (� ®Active ® Passenger ®Generator Is Outdoor <br /> _--_------ - _--------- --- O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility JENFORCEMENTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 orEX7) <br /> 0 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 0 Referred/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 IW In Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments <br /> i - <br /> Inspection Form Included: 0 u q� <br /> Comments Included: 0 �O C 4sp <br /> usin ep's Signature Phone Numberst r' gat re Phone Number <br /> INSTRUCTIONS ON BACK �Correct:0 Incorrect X �;. �/ f� A' p 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: ® ■ <br />