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a <br /> Waste Tire SL. ,ey & Inspection Report Inspection Report Number <br /> =61= State of California Survey Form - Page 1 I 1 - 1140903 <br /> CIWMB 187(New <br /> California Integrated Waste Management Board <br /> Part A--Survey - -_ BLUE OR BLACK IN_ K PEN <br /> Business Profile Inspection Details <br /> TPID- r Inspection Type (Fill one) <br /> 6 <br /> Site Suffix: , 7 9 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: io C �`�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Addressv <br /> �.SLtB J"�a i!t/i �, .4 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title0 AM AM <br /> A^ 0 PM r 0 PM <br /> /-� - - -- — ---- - --- -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / r� (Fill one only) (Fill all that apply)1 (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive • Truck <br /> Longitude - Q Planned Q OTR End-Use Container <br /> Business Type (Fill all that apply) <br /> j Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q DismantlerQ Tire Derived Fuel <br /> I <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other �/'ruZ �iLT�^F3,Z <br /> i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateM / 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 EXT) <br /> i _ <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> iQ 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 <br /> Q Q In Compliance - No Violations <br /> Other: § <br /> Comments J , <br /> "772.rr % r-.►?5'r�.n -,p e-0. ai O-Ap 7ze-+L <br /> e?.��:'�,� L � ^�i�Cyr�_-�v �- Y m��4.eC/-•1/1 °7� J^eu�^c �ilV/�t/ `�i'",, �•.f'�`7 <br /> Inspection Form Included: QI <br /> Comments Included: i <br /> - l Business Rep's Signature Phone Number Inspectors Signature __ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect E X A IL I I 131 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: ■ <br />