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0735404GG53 <br /> jMWaste Tire Survey & Inspection Report Inspection Report Numbed <br /> s��of�aefornfe Survey Form - Page 1 1 8 - 1 Q 7 3 4 8 9 <br /> CIWMB tea(Mew 041 4) <br /> California Integrate0 Waate Management Board - -- .---- �-- -- <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 9 , Inspection Type (Fill one) <br /> Site Suffix: I ®Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S4�n "�[a� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad ss <br /> I rvwry _i <br /> 4 0a W. -vap; _)4?d- <br /> `_ Inspection Date <br /> _L r4u� Gi} 5 5 3.76 - -- - <br /> =.ra'= Z10'_ode Time In Time Out <br /> Business Rep Title 1 I Q AM - ' - 7 Q AM <br /> i <br /> �PM 0 PM <br /> 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 /> f a ®Active Q Passenger ®Generator 0 Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude 0 Hauler 0 Indoo'r <br /> O O Inactive @ Truck <br /> Longitude — 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet O Government 0 Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station O Hauler 0 Agriculture Q Shredder 0 Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VIA HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 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 /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> e_ f <br /> ��-I[2'p jt.�t�ak r_• �� - vim <br /> Inspection Form Included:O <br /> Comments Included:Q { r Ph�L 23 <br /> Business Re�Signa , ne Number Inspector's Signature Phone Number <br /> �( 62081 <br /> ■ INSTRUCTIONS ON BACK Correct:* Incorrect: rJ X A M P L E 1 Z 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />