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I t <br /> Waste Tire Sup vey & Inspection Report Inspection Report Number ■ <br /> CIWMe81'fornia <br /> (New 04104) Surve Form - Paae 1 I 1 - 1143517 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- iLI - inspection Type ( -in <br /> Site Suffix: nRoutine Re-inspection0O Referral O <br /> Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: �� JQ�� J CC�LJ1� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 7S�11 <br /> Physical Address ( �� lJuivtt'7��C` <br /> 10,51 <br /> Inspection Date <br /> svnf-�A- 1 l q5�ot V <br /> Time In Time Out <br /> Business Rep Title O AMO AM <br /> ' l ® PM ®PM <br /> Cj- - --- - - — ---- -- —- ---- Operational Status Tire Type Business o elel Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ' O Active Q Passenger ® Generator Q Outdoor <br /> O ® Closed Q Altered !4 <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O 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 O Agriculture Q Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: 6 <br /> r <br /> Comments Included: i - - -- - -- <br /> Business Rep's ignature Phone Number ct 'Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect #1 <br /> I I 1 ; 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: <br />