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Waste Tire Su. „ey & Inspection Repoli . Inspection Report Number ■ <br /> CIWMB81California <br /> (New 04104) Survey Form - Page 1 11 - 1143700 <br /> California Integrated Waste Management Board <br /> Part A- Survey— BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: LI LI LI-- - 0 Routine O Re-inspection 0 Referral O Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - �— Inspected By Inspector <br /> C, <br /> Physical _ r_ <br /> Physical Address �� UJC✓ �re(►'Y� K7v <br /> Inspection Date -7 / c) -7 / lJ`; <br /> CA g5--xz�l <br /> Time In Time Out <br /> Business Rep Title / 0 AM 0 AM <br /> 0 PM Z (1 ® PM <br /> , eev t C ---- - ©wn� =-- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 56 4D Active ® Passenger 0 Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - O End Use 0 Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer •Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> --- - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQ UIREMENT5 <br /> O 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 /> O O - - - -. <br /> 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 <br /> Inspection Form Included: 0I <br /> Comments Included: III - - -73 - <br /> Business Rep's Signature Phone Number I s i9 nature Phone Number <br /> 62081 <br /> INSTRUCTIONS-ON BACK Correct.0 Incorrect i ; *� � i L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: ® ■ <br />