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Waste Tire Survey & Inspection Report Inspection Report Number <br /> fornia <br /> CIWMB 81'(Nw04/04) SurveForm - Pa e 1 I1 - 1141004 <br /> y <br /> California Integrated Waste Management Board J �+ <br /> - BLUE OR BLACK INK PEN <br /> A- Survey <br /> ness Profile Inspection Details <br /> f TPID- r� q �j I Inspection Type (Fill one) <br /> Site Suffix: , 5 �,[ l ` $ O l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `� If Referral,choose referral type(Fill one) <br /> Identifier: Sao J Q LO n (Ou 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> v�al�lnalI Cvn5f"t 440,n `� R - r <br /> Physical Address I � �SjQ <br /> X50 dk412r) - - - <br /> "1� -� i� Inspection Date <br /> Time In Time Out <br /> Business Rep l Title �j O AM U O AM <br /> " 1GL( W4 ��KII I PM S t ® PM <br /> V Qw�lr 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) 9 � <br /> 0 Active 40 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned t6 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Vew 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 Other 6174Ju461\ C Ploy <br /> Part D - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 or EXT) <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 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 'lt �k �� t f T Ut1 <br /> .1() <br /> t__IIml Wu Q, �rc._l tide �� � <br /> ks—A 014 <br /> No W'0144ring bC ZLkuS chi capmrn' - - <br /> Inspection Form Included: 0 ' <br /> Comments Included: <br /> usi ss RepkA <br /> s Signature _Phone Number Inspe is Signature hone Number <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: Y' X �4 d►4 p (� I �'. �] 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />