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Waste Tire SL.. vey & Inspection Repo► _ Inspection Report Number ■ <br /> CIWMB 81California <br /> 04/04) I 1 - 1144035 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey — _- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J l 5LtO ( Q Routine ® Re-inspection Q Referral Q Observation <br /> Local1n If Referral,choose referral type(Fill one) <br /> Identifier: Sv l �� WLM Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `�� ---- <br /> Inspected By Inspector _ <br /> _1 cervi <br /> Physical Address `� G( ( l t � t VtiL LAC <br /> ttzu-1.40 <br /> I—A C15-33 Inspection Date 4 L2 J_ d <br /> Time In Time Out <br /> Business Reps Title (�`� Q AM 0 AM Ci1G�' �Y',Gl.`✓CL�YI � � v � O PM � � � �— 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> _,�, <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ®Passenger Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 00Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End Use Container <br /> Q Planned Q OTR <br /> I <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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ® Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS 00 <br /> 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 DateM5 / MQZI <br /> / <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 /> 0 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Ic- <br /> Inspection Form Included: OIW4sln <br /> Comments Included: C ��� /(� �'/hsmess ep s SI ature P�ione Number ure Phone Number <br /> - - _ <br /> INSTRUCTIONS ON BACK [lCorrect:0 Incorrect: ;G A 1 3 62081 <br /> EX <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: A ® ■ <br />