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�s� �2a4oiss <br /> Waste Tire Su )y &_Inspection Report Inspection Report Number <br /> State of CaliforniaT 1 i <br /> 04104) <br /> California g CIWM d Was eeMa agement Board Survey Form - Page 1 L + + 10 8 8. 312 _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TSite Suffix:PID- �---' �-_— <br /> Inspection Type (Fill one) <br /> I /� 1 ��� =& SOL�L� I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: j� CZ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Physical .c t k S'c�ceo) C°sfr► cwt I <br /> A dressJf <br /> — – ---- – ---- <br /> _ _ I <br /> Stria O ' <br /> L— S I o Cyton n A �J�� Inspection Date I D II 5 I / <br /> C//'-,tI} —""_/ --j Time In _I _ I� Time Out <br /> Cit,v --"" -"�— -- Stati ZiP Core _ <br /> Business Re I AM I <br /> P Title r I n I O I �n� O AM <br /> I. O ;® PM �I PM <br /> 01 C' SCV-d S �� ge e <br /> 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 /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive (S Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULINGAND MANIFEST REQUIREMENTS <br /> lation <br /> Q Q Q Notice Of VioQ Extension <br /> 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 <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 DCS <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 Q Referred I C-IWMB 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 /> Q1 0 1Other: § --- -- -- ---- — c <br /> Comments �� <br /> 1 0p �7'L (( A n ofe,S � « _ e -6a 'C' <br /> l,CS.S Ao a i Wre fir refreaot 2k-LI I' ct- akLd X4-11 EngA t/2 Ay- <br /> �os C7Z /pctct 'c �s-t' Ar&_ s �/i e"Ied, 0 A vii cf-6l � S <br /> Inspection Form Included: Q �j' <br /> Comments Included: Qzz <br /> Kiginess.Rep's Wature Phone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK C• rest. ncorrect: X A M P 'L 1112 3 62081 <br /> White Co y CIW B Yellow Copy:Operator Pink Copy:LEA <br />