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■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> C�WMIB181,(Nw04104) Survey Form - Page 1 Il <br /> - 1127885 <br /> Califomia Integrated Waste Management Board �J �+ <br /> _ BLUE OR BLACK INK PEN <br /> Part A- Survey_ <br /> Business Profile Inspection Details <br /> TPID- C /_ I Inspection Type (Fill one) <br /> Site Suffix: ' J t V O 1 Routine Q Re-inspection Q Referral Q Observation <br /> LocalC 1 If Referral,choose referral type(Fill one) <br /> Identifier: J dl (1 �Q�j� l�j f� �,0�/l!�'p Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> M � - C-1I h <br /> Physical Address 31 l v n CSC06 <br /> �O�al� <br /> c Inspection Date LA I <br /> 1 Time In Time Out L <br /> Business Rep Title 0 O AM O AM <br /> • U BPM I ® PM <br /> br�,�,1r��o., - owner -- -- - <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) 3 rj <br /> Active a Passenger If Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j 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 I Date <br /> M / M / M <br /> 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 /> 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 /> i <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 <br /> in Compliance - No Violations <br /> Q Q Other: § --� <br /> Comments > > <br /> ---a-n� 1S—AlAk <br /> Inspection Form Included: Q, <br /> 17 Comments Included: p' 1 ` �� � � �v�� <br /> B In ss Res Signature Phone Number VIRsis Signatur Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ' Y X fl P ! p 62081 <br /> ® © ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L <br />