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jWaste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 1(New nage) Survey Form - Page 1 Il - 1140600 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> - P � <br /> _ Inspection Type (Fill one) <br /> Site Suffix: �o (A 3 1 Z 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: b ry� � ,�, ( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> rGtir,nn�nr, <br /> j Physical ddress `1 - (' / <br /> Inspection Date 1 Z <br /> CA I S2 t,, <br /> i' Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> 0 � 3 <br /> G • PM 0 S ® PM <br /> C2 Csz1 sz c,t✓ Z,F; /'�� /< <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 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude _ — 0 Hauler <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 /> C) New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ed Tire Dealer 0 Auto Body0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler ® Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , A 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 /> 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 /> ;tion Form Included: Q �Inspe --- — 0(.Comments Included: �Bu ess FF s Signature_ Phone Number r's-Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON ACK Correct:0 Incorrect: ,. X ;L I72 3 <br /> White Copy CIWMB Yellow Copy.Operator Pink opy:L <br />