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<<' Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMB California <br /> 81(New 04104) <br /> Survey Form - Paige 1 I 1 - 1143701 <br /> California Integrated Waste Management Board ! J <br /> P-+rt A- Survey_ _-_- BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> Inspection Type (Fill one) <br /> Site Suffix: ` I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r^ If Referral,choose referral type(Fill one) <br /> Identifier: <br /> SUO J UGl �� CO�{) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> D <br /> Physical Address ( ESrQ'��b <br /> D,5055 E . RJ - - - <br /> 9S3Inspection Date <br /> ao I <br /> Time In Time Out <br /> Business Rep Title 0 AM 0r\ 0 AM <br /> • 0 0 PM D V 0 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 /> 0 Active 0 Passenger I* Generator 0 Outdoor <br /> O 0 Closed 0 Altered 414 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned S OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) FJ��Lti t <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Jsed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder !g Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 - 0 Notice Of Violation 0 Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateM / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 014 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § \ <br /> Comments ; tk1 X45 Lam._ qS C. ll �15 -►'L� <br /> �1-a , ,cin neck r <br /> o �w; wt�5'CLc ��►'.. <br /> NO V�i Oku,�i t�f1S(2�s�SpC�i�L1Gef n= <br /> ,jection Form Included: 0 h <br /> Comments Included: * ��1�`�% <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: / <br /> � V � � rtl �rl,� � � � 62081 <br /> . Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />