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EE3 <br /> Waste Tire Survey & Inspection Report , Inspection Report Number ■ <br /> CIWMB81California <br /> (New 04/04) I 1 - 114 0 6 2 4 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A-Survey -__ _ BLUE OR BLACK INK PEN <br /> Aness Profile Inspection Details <br /> ..-ID- Inspection� � � � � - O � Inspection Type (Fill one) <br /> Site Suffix: 46 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: u� J j7«�Cj ul,1) co 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 1r � . <br /> Physical Adt�dFess(�gC C S q - 10 1 & n C-s.cob <br /> C <br /> CAq/J'1J 1G--slk Inspection Date 0 a S 10 <br /> a� Time In Time Out <br /> Business Rep Title O AM 2 ` O AM <br /> ' 0M; PM J I J 0 PM 1� Flo(d `- -FoJ�m� - - - -- - - - __-- <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 /> ' 0 Active 0 Passenger ®Generator ® Outdoor <br /> la Closed 0 Altered <br /> GPS Latitude 0 Hauler • indoor <br /> O 0 Inactive Truck <br /> Longitude 9 0 Planned OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> n 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 is Agriculture 0 Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V-1- A j HAULING AND MANIFEST REQUIREMENTS 0 Notice of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> M / 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 - - - <br /> +' In Compliance - No Violations <br /> 0 0 Other:''§ <br /> Comments <br /> `.L A1�1 AGI L• �S, '�7Lc, I ir)7 �Ci{ rN De,_ c,,fi c-nj-C-11-?C_ <br /> ,section Form Included: 0 <br /> Comments Included: S - - - - *26i7Yo2-8711 �(�(Ytl/Y` Ca�� L -YN <br /> usiness Rep's Signature Phone Number Inspect s Signature one Number <br /> - -- _ -- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect �/! E X A ,Mt P � � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />