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Waste Tire SL. .ey & Inspection Repork. Inspection Report Number ■ <br /> i114 State of California <br /> CIWMB 1(New04104) Survey Form - Page 1 I 1 1143584 <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 /> Site Suffix: L O l 0 Routine Q Re-inspection Q Referral Q Observation ! <br /> Local �1 If Referral,choose referral type(Fill one) <br /> Identifier: SAO O� u;V � n CoLkAi Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad re ss 31 CSC <br /> Inspection Date l <br /> Time In Time Outt!!! <br /> Business Rep 1 ( Title O AM ` Q AM <br /> vit <br /> 4. � `4L_ �Qj�Inw 5 e PM I J PM <br /> --- --- — — ---- — - ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r_ P1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �Q 0 Active Q Passenger 0 Generator Q Outdoor <br /> Latitude <br /> O Q Closed Q Altered <br /> GPS Q Hauler Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 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 Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FP / M / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1n� f 6� �1J _Vl� 1��l_l Xao 1 <br /> Inspection Form Included: x• 2'�2' <br /> p A _- o <br /> Comments Included: ( l <br /> Usines e�tuTe Phone Number Insp-tor's SignatuPhone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect i ,� p 62081 <br /> C <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py: ® ■ <br />