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Waste Tire Su*ey & Inspection Reporto Inspection Report Number <br /> State B California Survey Form - Page 1 i 3 . 1 4 Z 8 9 8 <br /> CIWMB 181(New nage g <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: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sao, (To aellf ta,0 00 (,(q;t`4 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -'j✓� <br /> inspected By Inspector <br /> ua �ectic� 'S rG W rvcklft <br /> Physical Address 3 <br /> _ tv C 1_to <br /> r / Of 9�5- Inspection Date G LI C 5 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> I o <br /> Latitude Is Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q 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 Q Auto Repair Q Trucking Fleet Q Government Q Retreader • Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> jQ Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> _.. <br /> ._ A: MAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q O 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 O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (I3equlred farNOV orEXT) <br /> ............... --.........---- -- <br /> Q j Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 1 Q !14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q R96.0ad I.0IWM9 Enforcement <br /> O I Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 10 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q other: § Q In Ogtrlpllalht�e No Violations <br /> Comments N0�- a Wase Til qeoe-v-a*c4-, A1ost- Vellfcles it, wrecki► �a.r <br /> Gje,l ivelred frt)m paaf-i c_ 7`f w vviAli 0uf hKe s or r;ms, Fer Il ty wi J <br /> disfo.se o-F wccsfz! hre.s ir) low ✓eh;eles ) per ve•Ilie,le oru,S11ed f, <br /> iF -�I��-� ccf�e +��Ps tL �►'s�o�e �F. Na 7�r,u� <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number I pector's Signature Phone Number <br /> INSTRUCTIONS ON BACK �Correct 640rot~t; vj <� _?�[r� fit,P Lft Y j 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />