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0808004002.5' <br /> Waste Tire Survey & Inspection Report Inspect*ion Report Number <br /> State rr . <br /> rr ClWMfCalNomla- Survey Form - Page 1 - I I 3 - 1 Q 7 9 4 6 5 <br /> CIWMB i81(New a age <br /> California Integrated Waste Management Baard' <br /> 'art A-Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 �z I ( 4 ( to Routine 0 Re-inspection : 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other. <br /> Business or Facility Name Inspected By Inspector <br /> I vV o-v K=S <br /> Physical Address <br /> 0 � R <br /> � 9 <br /> Street -1 <br /> Inspection <br /> Inspection Date <br /> City State Zip Code Time In Time Out <br /> Business Rep Title ®AM ®AM <br /> � 'WOPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> I I (Fill one only) (Fill all that apply) (Fill all that apply) .(Fill all that apply) <br /> Tire Count(WholelPTE) - ;.f I f <br /> I � ®Active ®Passenger ®Generator ®Outdoor <br /> Latitude �O 0 Closed 0 Altered <br /> GPS Q Hauler Q Indoor <br /> l_I_1-L I_I� <br /> v <br /> 0 Inactive 0 Truck <br /> Longitude – I. .. 1 -_ _. . _ _.—_L__ 1_. I 0 Planned ®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 ®Other I_�loor}t_�ca,�a S_J <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 /> 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 /> 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 t 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 /> VLQf e 47;o-✓\c <br /> Inspection Form Included:0 <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number( _Inspector's Signa-{ure Phone Number <br /> . I <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: V EII XI !thI R PI'L EI, I F 1 p'.ZI 3I 62081 <br /> . White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA <br />