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Waste Tire Survey & Inspection Re o#9 Inspection Report Number <br /> Y p p 0 <br /> State CIWMB California I 1 - 114 0 7 7 5 <br /> grated 9steManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEEN <br /> Business Profile Inspection Details - <br /> TPID- O _ � � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: Jo CQUdI Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Add ' S S P�1� 3 q - l o <br /> ress u <br /> `a01A '51 <br /> Inspection Date ' � / 0S <br /> Time In Time Out <br /> Business Rep Title ) � : 2 S AM Q O �Q PM <br /> J - PM_ <br /> - <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 /> Q Active Q Passenger Generator 0 Outdoor <br /> Latitude <br /> 0 + Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> 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 /> L4 t,�tl u,�►- d S GItiJ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder A Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 Q 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / M / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> 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 O In Compliance - No Violations <br /> Q Q Other: § _� <br /> Commeixi <br /> nts ,,, i <, <br /> ra A cya <br /> Inspection Form Included: Q <br /> Comments Included: -- -- ---- - �3-`� J��W��)�� -_ <br /> B ness Rep s Signature Phone Number Insper. is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect ,V X RP I I � 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink opy: ® 0 <br />