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® _ nt Waste Tire Su 1 & Inspection Repor� inspection Report Number <br /> State of California <br /> CWMB grated 1(New04104) Survey Form - Page 1 I 1 - 1141025 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 3 3 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S.,h 3104",t;t," �tiw Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> _� - - -- - <br /> Business or Facility Name' Inspected By Inspector <br /> Physical Address 3 <br /> ✓✓ Inspection Date l / 02 3 / <br /> �A 9S-01 s <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> {� v ® PM 0 3 0 Q ® PM <br /> Operational Status', Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 1 7 Z 3 <br /> ® Active Q Passenger ® Generator i ® Outdoor <br /> Latitude O Q Closed Q Altered <br /> i GPS Q Hauler I Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> l Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 ® Other iyWe_r Y,%5C �it <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility l ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q 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 i Q 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 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 Gornllarnde> ,No Violations, <br /> Q Q Other: § <br /> Comments <br /> - - - 1�4J i Y'tavtC�L -iGN� <br /> - - - <br /> JXZ <br /> Inspection Form Included: Q ^ <br /> x C�og� �jb —o6z <br /> Comments Included: - - - - ---—--- - - -- <br /> Q Business p's/� gnature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I.Cdrrect: Incorrect: �k' } r� A MIµ P i L 3 szo81 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />