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Waste Tire Su ey & Inspection Repo, , Inspection Report Number ■ <br /> =r= State CIWMB California f81 e 11 1143707 <br /> California lne grat dWaseManagementBoard 04/04) Survey Form - Page 1 <br /> Part A-Survey _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � � � � � 1 1 — Q- -� Inspection Type (Fill one <br /> Site Suffix: U' Q <br /> Routine Re-inspection Referral Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: S4 f J O k, r" C b Ul(1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Au%JJ4 <br /> Physical Address 3 — 1 b I &n <br /> x.35 d o t N cis Som QA <br /> 7�G (A Inspection Date I O <br /> J Time In Time Out <br /> Business Rep ,1 Title ,, O AM O AM <br /> 1 P , ('J�'1 a b 1` �i LI C�� O ® PM - --� O A PM <br /> - �� V- —�-- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f ' O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> $ Active Q Passenger O Generator 0 Outdoor <br /> O Q Closed ®Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q End-Use Q Container <br /> Q Planned OTR <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet S 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 /> Q Service Station Q Hauler ®Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS <br /> -- — i <br /> V1 A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle _P / <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q S 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 ® In Compliance - No Violations <br /> 0 , 0 Other: § L 1 <br /> Comments <br /> Iks <br /> Inspection Form Included: 0 <br /> � � <br /> Comments Included: � «� -�-y-/ )one <br /> uslness e s ignature Phone Number Inspect 's Signature Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IGf; JE X I rA MI P I L I E I 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� ■ <br />