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--•::a3 tit --...,.-----•- :�:.; <br /> ci= Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> k2CtWMB I1 - 1144029 <br /> S1ali(New Survey Form - Page 1 187(New 04104) <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A- Survey -. --- — - - ----- <br /> ness Profile Inspection Detal s <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: ` _ Routine Q Re-inspection Q Referral Q Observation <br /> Local \ � �n /+ If Referral,choose referral type(Fill one) <br /> Identifier: —— J t l �i1�1� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical �dttfess �J l CJI l tc JIJI <br /> `fi (� Inspection Date 41 ` <br /> � _7 "7 � l 0 <br /> tS t V L n k--'" , Time In Tiim�e Out <br /> Business Rep Title / �') O AM AM <br /> PM <br /> Operational <br /> 0 O PM / <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) , <br /> Q Active Q Passenger 0 Generator Q Outdoor <br /> — --- --- <br /> 00 Closed Q Altered 4Y <br /> GPS Latitude D Q Hauler Q Indoor <br /> Q Inactive O Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Aness 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 /> 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 Py,Cj�t�l� nC�" <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> 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 Date m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EX7) <br /> 00 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 4D In Compliance - No Violations <br /> 0 , 0 Other: § <br /> Comments <br /> Inspection Form Included: Q �) <br /> 2siinss <br /> _ - ddrtignature1 <br /> Comments Included: - --- <br /> Rep's Signature_ Phone Number_ Phone Number <br /> � 62081 <br /> INSTRUCTIONS ON BACK Correct. Incorrect: i i V) I III <br /> - '- <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />