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® Waste Tire Sup vey & Inspection ReporL Inspection Report Number <br /> 86= State B Survey Form Page 1 <br /> CIWMB 181 CaliforniafNew 04/04) y g I 1 - 1140953 <br /> California Integrated Waste Management Board <br /> + BLUE OR BLACK INK PEN <br /> A- Survey <br /> ness Profile Inspection Details <br /> TPID -- ' -� _ Inspection Type (Fill one) <br /> Site Suffix: S Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. S q� JU Ctj�J �� C(�lktf�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Ph sica Address J � � <br /> ^ 6�� Inspection Date <br /> Time In Time Out <br /> Business Rep TitleI* AM G #AM <br /> O S OPM Q ✓ S 0 P <br /> sknp - - -- b(y— — Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � r <br /> Q Active • Passenger It Generator Outdoor <br /> O Ik Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive 11111 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> U Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q I HAULING AND MANIFES11 T REQUIREMENTS <br /> I <br /> 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 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / 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 /> 0 O -- - -__ <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 ®In Compliance - No Violations <br /> Q Q Other: § --J <br /> Comments 10SQF,( l n.n <br /> � � r <br /> V4�i-on 5�o <br /> inspection Form Included: Q <br /> Comments Included:® —- —�l— G� 41npect <br /> Business Re Signature Phone Number 's Signature one Number <br /> -- --- �\� <br /> "� V! fk �. t 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect i , , <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />