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-= Waste Tire Sur Bey & Inspection Report Inspection Report Number ■ <br /> State of CaliforniaCIWMB T 1 — <br /> w 04104) <br /> California Int grat d181 Wast eManagement Board Survey Form - Page 1 I l 1140632 <br /> `1 A- Survey -- BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> rID- - O ( Inspection Type (Fill one) <br /> Site Suffix: 1 ` ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: n �tv�Lll n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> 4A <br /> Business or Facility Name <br /> ' 1 Inspected By Inspector <br /> Physical Address - b J I-1� rt L Ink <br /> 0\5x1 S ' <br /> - - - -- <br /> 1 f&( p �^ CA <br /> q�X l Inspection Date I / Q' 0 / <br /> \`t,�1 (`U,� N Y� `` Time In Time Out v <br /> Business Rep Title O AM Q AM <br /> PM 3 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 /> 7 0 Active Passenger Generator 0 Outdoor <br /> - O <br /> �+ Latitude • Closed 0 Altered <br /> C7PJ 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0-Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> _ Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VF­AjHAULING AND MANIFE—ST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FP / 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 0 14 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 � <br /> 1 1 f sic. ,_g / <br /> �1 <br /> rection Form Included: 0�1 <br /> Comments Included: 48 <br /> -- - <br /> Bu me ep's ign ure- Phone Number - Inspecto Signature _- no Number J <br /> INSTRUCTIONS ON BACK Correct * Incorrect I V ( 0 CV] 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />