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t . Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1140577 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> 1- <br /> Site Suffix: I `D 2 7 -7 ' � _ � ' Inspection Type (Fill one) <br /> I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: C(d� � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> "aa <br /> Physical dress !/ 3 � — f 0 <br /> 8330 Or; 7 <br /> Inspection Date <br /> 9'S2,1 S' <br /> Time In Time Out <br /> Business Rep Title / O AM / Q AM <br /> PM O ` S • PM <br /> —- Operational Status Tire Type Business Role <br /> Tire Count (Whole/PTE) l A O (Fill one only) (Fill all that apply) (Fill all that apply) <br /> Storage Type <br /> (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned __0 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 /> sed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other � <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V : A HAULINGANDMANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> A __ <br /> Q O 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. O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / j / M3 ,, / Q <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/GIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> ���� ;h c(x c,fa=�7ti crw__ •{-L�, � ���- �CrtG+� �2 ��Ccn,.��y �,.�°< r <br /> I :tion Form Included: QI <br /> Comments Included: -- - ¢ p` - -- --- — <br /> •,Bu Hess Rep' Signature hone Number In pector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: 1 k p 1 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py:L 41 v r <br />