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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State CIWMB California 11 - 114 3 5 8 5 <br /> grated 1st(New Manag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> t A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> � Inspection Type (Fill one) <br /> Site Suffix: i Routine Q Re-inspection Q Referral Q Observation <br /> Local e— 1 If Referral,choose referral type(Fill one) <br /> Identifier: an Joa_ ��n �U�n'� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 13 -),°►3 C . Ldu, s� Avr-- <br /> m Ake-e- C A 9 5 33G Inspection Date u / ' Q <br /> fi.. Time In t Time Out <br /> Business Rep 11 Title O AM Q AM <br /> \AtkcaWU ()u)rr- — PM I J V PM <br /> - - - - - - - - - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' /r� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Passenger ® Generator Outdoor <br /> 0 ®Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> � i <br /> Riisiness Type (Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 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 1 Q 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 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 f CIWMB Enforcement <br /> Q Q 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 /> Q Q Other: § j <br /> Comments <br /> action Form Included: Q g���Q�4 <br /> I ' +1 I e 1'7 <br /> Comments Included: ®j V - CoC�J 100 �� / g <br /> B ine Re ignature Phone Number Ins�,,, ature _ _ Phone Number <br /> INSTRUCTIONS ON BACK Correct.9 Incorrect i 'l E XIA �J EI 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />