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s <br /> Waste Tire SuRd#& Inspection Report ection Report Number ■ <br /> State California I 1 - 1143537 <br /> CIWMBB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- i `1 t� n _ O 1 InspectionRoutine <br /> Type (Fill one) Q <br /> Site Suffix: l dC I l Routinin0 <br /> e Re-inspection Referral Observation <br /> Local t^ t If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -- <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad ress 3 1 V Be-n E5�0�-b <br /> X050 Sic, ion tic <br /> \ k� ,L11 <br /> C A l S-a1,5 Inspection Date <br /> �' /J U n Time In Time Out <br /> Business Rep Q I Title �j 0 AM 0 AM <br /> o � -�.._-r 0 PM � � � 0 PM <br /> r Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active 0 Passenger * Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 41 Auto Repair Q Trucking Fleet Q 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 Q 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 /> QQ 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 Date m / m / m <br /> 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 /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -- -- <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: § <br /> Comments <br /> I�t L�1L L X21 _ <br /> - <br /> Inspection Form Included: QII <br /> Comments Included: <br /> atur <br /> b .lloneu��31� <br /> I �Business Reps SignPhone Numbe>f `�4 spect is Signa re Number <br /> INSTRUCTIONS ON BACK ICorrect:0 Incorrect , I "kC <br /> t 62081 <br /> ■ --. - y:- r ® E <br /> White Copy:CIWMB Yellow Copy:Operator <br />