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Waste Tire Sur,_ y & Inspection Report ,ispection Report Number <br /> �WMB <br /> 81California <br /> (New04104) Survey Form - Page 1 I1 - 1140878 <br /> California Integrated Waste Management Board J <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f ) ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �dtIV1 rGctLdt�tt,�l�� �- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name--�—� J U Inspected By Inspector <br /> (20 zctGL /I–LGr CQ�r–S C <br /> Physical Address 1 – Q - fit & 4-44 <br /> CAInspection Date / 1 r - / I <br /> to r.�Kl-vr� I Z 1•S t�11 <br /> Time In Time Out <br /> Business Rep Title j L 3 m AM ®AM <br /> 0 P 3� 0 P <br /> am R-S f41_f.4C-h 1 0 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 /> 0 Active 0 Passenger ®Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V 1 A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <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 <br /> M / M / 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 /> 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 /> Jam' <br /> Inspection Form Included: 0 --- 7-0 1j l� <br /> Comments Included: '"�J yIG 7T- 6 L <br /> Businw�ftep's Sign Phone Number Inspector's Signature _ Phone Number <br /> _ — /- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect V1 im X A 3 <br /> - - _ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y: <br />