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® por inspection Report Number <br /> Waste Tire Sur .;y & Inspection e !� <br /> Willa StWMBate 1CaliforniaaSurvey Form - Page 1 ( r' - Q 3 a d 2 <br /> CIWMB (New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey Wryl;vl , QA"vvre " j NAIL k- IzAi�Vvl BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detal ) <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: tJ �� L7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: \O'Z Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name lV Inspected By Inspector <br /> Physical res v C\ — U <br /> 7 <br /> Inspection Date yl U <br /> 5 `CC <br /> �.tSk _ �C�-v� Duµ Time In Time Out <br /> 5 <br /> Business Rep Title I'AM 0 AM <br /> S O PM li Z J 0 PM <br />(e�yr <br /> t <br /> �'°>> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) at <br /> Active Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> iO Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use # Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 Q Agriculture Q Shredder Q Other <br /> -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS_ <br /> VV A 'HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EX7) <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q ® 14 CCR§18459.3-Retention of Manifest Forms and Tire ri dogs for 3 years ` <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers i Q Referred/CIWMB EnforCeirlen <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities t <br /> Q .W'f 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators * ` <br /> In Compliance No Violations <br /> 0 O Other. § l ( ------ — - -- <br /> Comments <br /> S.&A­ <br /> 5 <br /> A, ; �L� >Vf7 c3Irl <br /> 53 <br /> d <br /> Inspection Form Included: 0 <br /> Comments Included: Q' ���✓� �D� — � ��`� <br /> Business p Signature Phone Number <br /> In pector's Signature Phone Number_ <br /> INSTRUCTIONS ON BACK Correct Incorrect ( i �/�I XI A MI F j L 1 j 2 13I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />