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s®� <br /> Waste Tire Su 1-y & Inspection Report Inspection Report Number <br /> State of California - <br /> Cgrated a(teManag) Survey Form - Page 1 Il - 1140908 <br /> California Integrated Waste Management Board <br /> Part A-Survey, _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection f � � - / Inspection Type (Fill one) <br /> Site Suffix: (•a 342 <br /> O0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ju,94,00 �j 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Nam <br /> Inspected By Inspector <br /> Physical Ad=s ;3 o / <br /> Inspection Date / / / 0 <br /> 'Ira cC 1�3G`/ <br /> Time In Time Out <br /> BusinRep Title 0 AM 0 AM <br /> -YvfCA (-CLP � �rcz �'�lr�,wsw U � 3 /, � �® PM_ - V -,2 <br /> - ® PM <br /> �r S pLtf✓f c f�t.Vvt[t ' <br /> -- �X 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 /> t 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler i ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 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 /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V„ A HAULING AND MANIFEST REQUIREMENTS <br /> 0 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 Q 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 /> 0 0 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 1 0 1 Other: § <br /> Comments <br /> Inspection Form Included: 046%__ <br /> Comments Included: ® -- <br /> r�o►-�;i 1.2 oes) yG�'-cam 3 <br /> Burin s ep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X y X A 1 I 3 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Co <br />