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Waste Tire ROW & Inspection RepalMspection Report Number <br /> State of California Il 1127465 <br /> California Integrated f Was81 tJe Manageew lment Board Survey Form - Page 1 <br /> Part_A-Survey _- --__ __- _BLUE OR BLACK INK PEN <br /> Business Profile l Inspection Details <br /> TPID- _ r Inspection Type (Fill one) <br /> Site Suffix: $ I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�� Jou,\ n vu� O CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Fe-vz' 'o'�' Q\ C. <br /> Physical Address o I <br /> Inspection Date Z <br /> Time In Time Out <br /> Business Rep Title I O AMQ AM <br /> ` S PM O (9 PM <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 /> ® Active Q Passenger ® Generator O Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive ® Truck <br /> Longitude - O Planned__j Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair ® Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer O Collection Q Crumb Rubber LL <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other &_rVjw`Cf\ i11Qj"n �pl�)uc7ft)S <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q O 14 CCR§-18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 114 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FJC7) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers j Q Referred/CIWMB Enforcement <br /> 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O i O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators It In Compliance - No Violations <br /> Other: <br /> 0 6 <br /> Comments Q 0U1,�1�Q,� I` 1�'[1Vf� ��� � l��a✓� Gl'n(� � ltU _ i �_1- � �(A <br /> (�0 V'ko w o RS��(Jt`fe.< s--_b -_ C,(flCer n <br /> 6A WiA Slb) W .- b f CDS uK uk -- T (c.s eAA 6\. �i(`(1.2- <br /> Inspection Form Included: -CI-) (10 <br /> Comments Included: O <br /> i - - <br /> - - slness Rep's Signature - Phone Number— Insp tor's Signature Phone Number <br /> _ <br /> - - - /- 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect. �/ E X A M f 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop 'L <br />