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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMg81'fornia <br /> (New 04104) Survey Form - Page 1 Il - 1127909 <br /> California Integrated Waste Management Board J <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I b 3 0 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �U,n J Op(� �;nq Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name " lV ,J Inspected By Inspector <br /> (kss <br /> Physical Address <br /> L� C A Inspection Date � � JLD � l <br /> Time In Time Out <br /> Business Rep Title I I { 10 AM a AM <br /> I e <br /> ` l J 0 PM ` 0 �J 0 PM <br /> Ue e, - `-"-- - SS - - — — V Operational Status Tire Type Business Role ; Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Active Passenger Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q Planned I Q OTRQ End Use Q Container <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other �,n <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityEN OF R EC MENT STATUS <br /> V ! A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 Date 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 i 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: § 1 -1- <br /> Comments IJV�q'�'1��-�1�� i c� x-6(9 4—_ (r _ 4 r\ S p_ar) <br /> loAI o-tom` VY-4,S aO�Cj- --- - - - - - -- -- -- <br /> - <br /> J - I <br /> Inspection Form Included: Q `e /,L <br /> Comments Included: r JCS � ���3 D4 <br /> — --.. -- - - - - - <br /> Business Rep's Signature Phone Number Inspec 's Signature Phone Number <br /> ---_ -- , �� 62081 <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: X �' E X fl M L 1121131 <br /> - -- - - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />