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GE3iCiar3 <br /> Waste Tire Survey & Inspection Report : .Inspection Report Number <br /> State of California <br /> Cgrated asteMaage Survey Form - Page 1 .I 4 - 1 0 7 3 5 44 <br /> California Integrated Waste Management Board <br /> Part A-Survey_ _ _ BLUE OR BLACK INK PEN <br /> Business Profile' �� Inspection Details <br /> TPID- - 'I / I ,, i / y O / Inspection Type (Fill one) <br /> Site Suffix: �7 1 9 � (*Routine Q Re-inspection. 0 Referral Q Observation <br /> Local If Referral;choose referral type(Fill one) <br /> Identifier: Cm 0 CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name AA . Inspected By Inspector <br /> � � <br /> I A f 0 Y I G <br /> Physical Address 3 / – C7 / <br /> 1 103 e. CAW Sh. I <br /> Street <br /> Inspection Date <br /> I to SZt(� Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title m m)6 AM 0 AM <br /> *PM m m O PM <br /> Operational Status Tire Type Business Role: Storage Type <br /> 1 l i (Fill one only)' (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) I�, I � I f�� I <br /> Active. ®Passenger I .Generator. *Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude W O Hauler 0 Indoor <br /> I—TI�—SII D O Inactive Q Truck <br /> Longitude – Q Planned Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ®Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler. O Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection O Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> (�Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / I]] / m <br /> Q O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days. (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O '14 CCR§18460.2-Manifest System Requirements forRegistered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste.Tire Generators ®In Compliance - No Violations <br /> 0 O Other: § <br /> Comments D <br /> KIg6e*9Lh <br /> Inspection Form Included:Q <br /> Comments.Included:Q <br /> X — �h.pet.lsBusiness.Rep's.Signaturoneumer_. Signature. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: fr X M P E:L Ti `2 3 . <br /> ■ White Copy:ClWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />