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;L= Waste Tire SL ey & Inspection Repor, Inspection Report Number <br /> bra- <br /> State of California <br /> CIWMB 781(teManag) Survey Form - Page 1 1 6 - 10 7 2 8 7 7 <br /> trri._ <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � � Inspection Type (Fill one) <br /> 2 <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SAl� Jo t t r� �av n O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cos r-c o 3 l 0 <br /> Physical Address <br /> 2 Inspection Date D q � 2 � <br /> T�C ( C-A 53�� Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ' O PM QPM <br /> ;e C<-40Y) M 6_72 <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 0 Active if Passenger ® Generator O Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O <br /> 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 i Q 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 Compha. e N <br /> 0 Q Other: § <br /> Comments fOt fTiN Fd fAj,S0,fC.; i c7IJ dkj /)71S J4-A- �/le ��/OI.JIAJQ IJM �i�J.' <br /> �� C-4'lr' r��d.•11;a �44,A) ri/ — r.J/es- r. E� gA/4M/`oc12 Kc G.eJ,nja► <br /> /lj6%r t�ls1 i S�T �.4 w�erS N1.4A/itC S f"s tai�e ul GctO N� <br /> Inspection Form Included: O <br /> Comments Included: Q q63;z�-- - - <br /> _ Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK gaff01 ', _ c .y XIAIMIPILIEI 111213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />