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Waste Tire Sup vey & Inspection Report, 'inspection Report Number <br /> "t CIWMB 81'fornia <br /> (New 04104) Su rVe Form - Paige 1 Il - 1143622 <br /> California Integrated Waste Management Board y J <br /> Part A-Survey_ - BLUE OR BLACK_ INK PEN <br /> Business Profile J Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: d (� 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalI If Referral,choose referral type(Fill one) <br /> Identifier: S(�{� �(�(.CC� lam)r) CiJll{C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> W 0-44' 0 � a; f 3 _ p <br /> Physical Address I �S Li.IJ <br /> S, <br /> �� Inspection Date <br /> L;n�� <br /> Time In Time Out <br /> Business Rep Title O AM [ C, O AM <br /> ' 41 PM J J A PM <br /> - - - ---- - �- <br /> Operational <br /> Status (FII irea Type <br /> apply) (Fill all that apply)ess Role i Storage Type <br /> Tire Count(Whole/PTE) QFill (Fill all that apply) <br /> u 0 Active Q Passenger ® Generator ® Outdoor <br /> GPS O <br /> � <br /> Q Closed Q Altered <br /> Latitude I Q Hauler Q Indoor <br /> O Q Inactive 41 Truck <br /> Longitude - Q Planned If OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0-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 <br /> Lai- _ - - M <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ----- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> O O (Other: § _ - <br /> Comments af 11 A:V\ Mal ),W� <br /> c� V'Aal i tin o fQ feac, _U)r\(e- 'n <br /> Inspection Form Included: QIP <br /> Comments Included: �rJ�l l`��1) �lo'5331 110 D�Jl�u <br /> Bu mess Rep's Signature Phone Number Inspe�Signt/, one Number <br /> INSTRUCTIONS ON BACK Correct:0 -Incorrect X 1 2 3 62081 <br /> ` ' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co101( <br /> ® ■ <br />