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Waste Tire Su. vey & Inspection Repoi . Inspection Report Number ■ <br /> State B California Survey Form - Page 1 Il - 1144040 <br /> CIWMB 181(New nage) g <br /> California Integrated Waste Management Board "�' <br /> n^rt A—Survey _ __— - _ _ _ _ _-_ _. BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> r'ID- _ Q � Inspection Type (Fill one) <br /> Site Suffix: lJl e Routine Q Re-inspection Q Referral Q Observation <br /> Local �1 � � If Referral,choose referral type(Fill one) <br /> Identifier: SQ ' �� yr b Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Z_iyNcGtY\- Ute.►liec .-.cc' l Z7 l <br /> Physical Address ( t�lex, -�rn btJ <br /> �� <br /> _ Inspection Date 4j1 9 % <br /> R7�,7D�7 6 <br /> Time In Time Out <br /> Business Rep Title �} * AM ` *1M <br /> 9((�� `/ \\� l.' c_ O PM ` O PM <br /> 66 \' 'ClCti1r V% Lax)1iec�t Intim - - -- ---._ - -- - <br /> - - ---- - - - ------- ---Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude O O Closed Q Altered 'IA 'V14GP. O Q Inactive Q Truck Q Hauler. Q Indoor��A <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V IA LING AND REQUIREMENTSMANIFEST Q Notice Of Violation Q Extension <br /> Q Q PRC§ R9 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 Date <br /> M / 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 /> 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 /> 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 1 Q 1 Other: § <br /> Comments <br /> Tie,n <br /> �J <br /> _pection Form Included: OI <br /> C n Q <br /> Comments Included: ® - - 0(,Nc))-F5-;-- ��l' <br /> - - <br /> usiness Rep's Signature hone Number Iris ec s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect �/ E A M P I L � i � � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />