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rw Waste Tire Survey & Inspection Report inspection Report Number <br /> L = Slate B California I 1 - 1140586 <br /> Cgrated 1(New <br /> Manage( Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ -_ BLUE OR BLACK INK PEN <br /> R---iness Profile Inspection Details <br /> - Inspection Type (Fill one) <br /> I'Me Suffix: / �, z 3 3 / to Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 57 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name kJ- iV <br /> Inspected By Inspector <br /> Physical Address cAL <br /> Inspection Date 0 / Z_ / G <br /> 32-0Inspection <br /> In Time Out <br /> Business Rep Title / ® AM 0 AM <br /> / 0 PM 0 ® PM <br /> /�,-f kms:G� 1 �►t�i�.- ��;�-r <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 /> (r�} 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered N/A <br /> GPS Latitude N� 0 Hauler Ajf 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Buslness Type (Fill all that apply) <br /> 0 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 Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler ® Agriculture v 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 m / m / Fn <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 /> 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 /> li :tion Form Included: 0 <br /> Comments Included: le -//_ �e <br /> ='.... - - - ----- =7 - <br /> as S' turePhone Number spector's Signature Phone Number-- --- --- - J <br /> -- _ _ ,.,........... <br /> INSTRUCTIONS ON BACK Correct:4D Incorrect: X �, �f j ' I 11 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co91-141/ <br />