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F� Waste Tire My & Inspection Repsolnspection Report Number <br /> ■ III State of California <br /> CIWMB1811(New04/04) Survey Form - Page 1 I l - 1143812 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,� � ,e, � Q � � Q I Inspection Type (Fill one) <br /> Site Suffix: v l @ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localr— t If Referral,choose referral type(Fill one) <br /> Identifier: A(\ U.q (1 <br /> J Qw �U{���A 0 CHP Q CIWMB Q Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 •1 <br /> p Inspected By Inspector <br /> G&m - v iA <br /> Physical Ad ress <br /> 5� <br /> Inspection Date / o / <br /> �L 4C V Time In Time Out <br /> Business Rep Title /, O AM O AM <br /> n 0.53(\ F1L 0 V ® PM 3 y 5 ® PM <br /> - Operational Status: Time Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j1 (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 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 &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 I 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 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 /> 0 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 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 le In Compliance - No Violations <br /> 0 1 0 1 Other: § <br /> -- I <br /> Comments `11 1_f,l Ju IyjgL S 4 <br /> 00 <br /> �S S <br /> Inspection Form Included: 0 <br /> Comments Included: 0 U--317 <br /> Business Rep's Signature Phone Number Inspect Signature ___ hone Number <br /> INSTRUCTIONS ON BACK �Correct:* Incorrect: iG t ,� )C P 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:L ® ■ <br />