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.: <br /> Waste Tire Su, ;y & Inspection Repor"nspection Report Number <br /> State B California Survey Form - Page 1 Il - 1140771 <br /> CIWMB 181(New nage) ry <br /> California Integrated Waste Management Board y <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> i Business Profile !Inspection Details <br /> TPID- p Z r + _ 0 Inspection Type (Fill one) <br /> Site Suffix: / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ' If Referral,choose referral type(Fill one) <br /> Identifier: Son /, , ' w 6�,, /�, 1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> 'Business or Facility Name �(J'v" -" J <br /> Inspected B <br /> p y Inspector <br /> Mau. va y f� _ <br /> i Physical Address o 3 ` <br /> Q Inspection Date <br /> vY►kCam. CA /S'3,3i <br /> j Time In Time Out <br /> i Business Rep Title � � Q AM � � � Q AM <br /> Mtt�Ci.>`Jv ��v'Lt_C.G✓ � � �`Z�(� — ® PM � — ® 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) 1 (Fill all that apply) <br /> � f <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck 1 <br /> Longitude — 0 Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) tv/A kii A <br /> 0 New Tire Dealer 0 Auto Repair Is 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 /> j <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V „AHAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> --- <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 <br /> 0 0 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 0 Other: § --_ <br /> Comments <br /> ax - <br /> `fZce llc�w rrt� 44,(e r e-w - - - — <br /> Inspection Form Included: Q <br /> Comments Included: ®I — -X �Zv�i� '-1(p�- tab 2 <br /> Business Rep's Signatu e P ne Number �spectorl;s gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />