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Waste Tire Survey & Inspection Repo, c Inspection Report Number ■ <br /> State of California I 1 - 1143696 <br /> CIWMB181 <br /> asteManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> +ASurvey __--_- BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> 1 PID- Inspection Type (Fill one) <br /> Site Suffix: 5 $ 3 © l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local }� If Referral,choose referral type(Fill one) <br /> Identifier: � �C�6r l Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phys a Addres l 1 A lC� yyy , <br /> 5S. &h n3mct vj -- <br /> Inspection Date <br /> ( Time In Time Out <br /> Business Rep Title O AM 2 ? O AM <br /> $ PM v J 0 V PM <br /> (me--�Qi r � Operational Status Tire Type Business Role Storage Type <br /> J (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> O Active Q Passenger ® Generator ® Outdoor <br /> O a Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — O Planned Q OTR O 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 O Tire Derived Fuel <br /> v 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O - -- - -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years i <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i <br /> Q14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance No Violations <br /> Q 1 0 Other: § <br /> Comments <br /> m t n- c4T A).c--- <br /> 1�7 <br /> spection Form Included: O <br /> Comments Included: ® - - -- - <br /> 8,559// <br /> ! sines p's Signature Phone Number In or. nature Phone Number <br /> INSTRUCTIONS ON BA Correct:* Incorrect Vi { ! N, P ( 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />