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........... <br /> ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of California 11 - 1127891 <br /> CIWMB 1 B1(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK-PEN <br /> Inspection Details <br /> Part A-Survey <br /> Inspection <br /> Business Profile spe <br /> Inspection Type (Fill one) <br /> TPID,- 0 ( 0 Observation <br /> C) Routine 0 Re inspection 0 Referral <br /> Site Suffix: <br /> Site <br /> e referral type(Fill one) <br /> Local If Referral,choose Educational Visit 0 Other <br /> 0 CHP 0 CIWMB 0 Complaint 0 <br /> Identifier: <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> \\A -S 0 N A <br /> _ 1fN Inspection Date <br /> 0\ U." C A �5 Time In Time Out <br /> 1 0 O0 AMl 3 5 e <br /> 0 AM <br /> Business Rep 11 Title 0 PM PM <br /> RPPY) <br /> Type <br /> Business Role <br /> kV64 all <br /> apply)—Operational Status Tire Type ply) <br /> all that apply) (Fill all that apply) (;Fill all that apply) <br /> (Fill one only) (Fill <br /> Tire Count(Whole/PTE) -1 50--_ *Active 4j Passenger 4j Generator 0 Outdoor <br /> 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> GPS Latitude 0 inactive 40 Truck <br /> 'v <br /> DQ <br /> 0 End-Use 0 Container <br /> Longitude Planned 0 OTR <br /> Business Type (Fill all that apply) 0 Tire Derived Fuel <br /> -king <br /> 0 Trucking Retre der 0 Dismantler <br /> New Tire Dealer 0 Auto Repair Fleet 0 Government 0 <br /> 0 Used Tire Dealer 0 Auto Body 0Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 service Station 0 Hauler 0 Agriculture 0 Shredder Other WN04 ISG �I <br /> Part B - inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FENFORCEMENT STATUS- <br /> V A HAULING ANDMANIFESTREQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Ire <br /> Insion <br /> g Req' <br /> 0 0 PRCi§42956-Registration/Decal in Vehicle 7 Requiremm / m /ents <br /> 0 r014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 2 1 C, m ID Number from CIWMB 0 0 14 CCR§18459.1 -Tire Program go I (Required for NOV or EXT) <br /> in days <br /> Trip Logs within 90 days <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> W st ire Haulers 0 Referred J CIWMB Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Hauler] <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> t <br /> 0 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I In Compliance No Violations <br /> 0 0 Other: § <br /> Comments 0 <br /> PA <br /> 04 ugl�o- <br /> C_ <br /> .1 Inspection Form, Included: 01 o46 0_731-70. <br /> Phone Number <br /> h <br /> ornments Included: 411 siness Rep's Signature Phone Number----- Inspec s Signatur <br /> 62081 <br /> Correct:0 incorrect: -V E X A P L <br /> INSTRUCTIONS ON BACK I <br /> i I - ® ■ <br /> White Copy:CIWMB Yellow copy:operator Pink Co y:L <br />