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Waste Tire Sul „ey & Inspection Report Inspection Report Number <br /> 416i State of California T <br /> ew 04/04) <br /> California Integral d'81 Waste Management Board Survey Form - Page 1 1 1140635 <br /> 'art A- Survey __- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: .J V I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r' If Referral,choose referral type(Fill one) <br /> Identifier:- Sa J 0a// �k n co"(�n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Fac i Ity Name "►L <br /> Inspected By Inspector <br /> 0(, �Of) _ r <br /> Physical Address 3 I O ( Bcn j , ko <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep {�(� Title O AM 1 , O O AM <br /> Y e�C 1-� LAxci S2 C.1C�k� 3 O PM L•' - O • 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 /> rj <br /> Q Active Q Passenger ® Generator 0 Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 ®Other 1�C�C 11 r <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 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 EXE <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 /> Q Q Other: § <br /> Comments Se 6.4 <br /> IV n Vif��aT�c�fl� cteU S 4 u)n(Crn - <br /> Inspection Form Included: Q' 1 <br /> Comments Included: -- - -- e- <br /> ��Business Rep's Signature Phone Number Inspect 's Signature _ one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X (�iyI�L XJ A 111 Z 131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y:L <br />