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Inspection Report Number <br /> Waste Tire Su vey & Inspection Report <br /> 117 C1N/MB 81California <br /> (New 04/04) SurveyForm - Page 1 I 1 - 1088322 <br /> n_ California Integrated Waste Management Board _ BLUE OR BLACK INK PEN <br /> rt A- Survey _._ --- -- ----- - <br /> iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalC �+ If Referral,choose referral type(Fill one) <br /> Identifier: Sexy Scc�!/1A �-CXJyUh—/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l I' n1'b� <br /> A-Y,t✓. (S-i-, cm�4- -?If- <br /> Inspection Date I cl > Q <br /> L r� CA qS.-No Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' III PM PM <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 /> O 4 Closed Q Altered /V/A A/44 <br /> / Q Hauler Q Indoor <br /> GPS Latitude O Q Inactive Q Truck�(�� <br /> Longitude — Q End-Use Q Container <br /> Q Planned Q OTR <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 ® Other Al /A <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V r A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 / 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments _ <br /> ( 11n�{vh ct r tin Sdr✓c:h c'czc}� I t 4� ✓1 . <br /> r�tC� lrr• v' ._ + r �Emoe✓ G�D2�rc,, �1�"` Sr t-G G��['�22�,�5 ( :✓ <br /> l � <br /> Inspection Form Included: Q <br /> Comments Included: Q '-- � <br /> Business Rep's Signature Phone Number In ct r' Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 0( R PtLIE1 11121:3] 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA EA <br />