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-i Waste Tire & Inspection Rep Inspection Report Number . <br /> State CIWMB California I l 112 7 4 6 6 <br /> California Int grat d Was181 te Manageew 04104)ment Board Survey Form - Page 1 <br /> Part-A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - ® Inspection Type (Fill one) - -- - <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �a,e� Oct 4){ ) COIAn� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or-Facility Name Inspected By Inspector <br /> ,�/� 17 S <br /> Physical Address� iq D 1 &n <br /> is 33 <br /> SInspection Date � <br /> Time In Time Out <br /> Business Rep Title 0 AM ` (� Q AM <br /> ' (v� O PM 1 ® v PM <br /> Operational Status I Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 [' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t J Is Active I& Passenger 0 Generator o Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use o Container <br /> Business Type (Fill all that apply) <br /> ® 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 /> o Service Station o Hauler 0 Agriculture o Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> 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 /> 0 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 o 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 1 Other: § 11 <br /> Comments <br /> or -(�s�uo� c.c�LY� r✓1 _ <br /> ,J <br /> el <br /> 1 - <br /> Inspection Form Included: of <br /> Comments Included: - -- q <br /> - - Business Rep's nature Phone b2��" y3kerols Signature ((IJPhone Number <br /> INSTRUCTIONS ON BACK Correct.* Incorrect ) }� Aq, M 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE ® ■ <br />