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Waste Tire Su� ,iey & Inspection Report Inspection Report Number ■ <br /> =:o= State B California S urVe Form - Pa e 1 I 1 - 114 0 6 2 9 <br /> CIWMB 181 t eManag) Y g <br /> California Integrated Waste Management Board `�' <br /> °-rt A- Survey -__ _- BLUE OR BLACK INK PEN <br /> ---- ---- ---- <br /> iness Profile Inspection Details <br /> ID- j u Q� /� Inspection Type (Fill one) <br /> Site Suffix: l 5 3 I 1 Q 1 v l Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S4(� J(��9�� CC?tJl��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> N1 t <br /> X\f�(.�, 0� 5�emi q - Q <br /> Physical Address I &0 �S�� <br /> ^ O 1 q CJ 4^ Inspection Date I O a L <br /> LJ�►- ,{1-,17_ 1 j.�U) Time In Time Out <br /> Busiinnesss,R�ep `_ Title 1- r` O AM O AM <br /> 1 YL� CW rt v' O1(� �Jt)A\J A4-v f� M �. V e PM 5 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 •Generator Q Outdoor <br /> O db Closed Q Altered NAl <br /> GPS Latitude Q Hauler Q Indoor �l <br /> O Q Inactive • Truck <br /> Longitude - Q Planned 10 OTR Q 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 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 ® Agriculture Q Shredder Q Other <br /> I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> y ! A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or-Waste Tire Generators �In Compliance - No Violations 1 <br /> Q Q Other: § I J <br /> Comments T � l .� f � 1 , Lill I- _I <br /> J..n,�a �' td,`Jf c. 1 �- t n 'f '17n (�s�u f n1 n '� T '1 1Sa <br /> 1� O U�c��a1�i c�0 CSS al-c-Q-S fj c a 1t [�r n, - -- - <br /> Comments Included: Q ., C� 1 o // G Q <br /> eCom Form Included: ` `' " I_ _ __ !�l _ Qvv �CJ�C{ `1100-�I7U <br /> � � Business Rep's Signature Phone Number Inspect s Signature Phone Number <br /> - - --- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect �, �/ E A M E� t 1 2 ] 62081 <br /> ■ White ------ —- —-------- — - - ® ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />