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Waste Tire S-.rvey & Inspection Rep( Inspection Report Number <br /> Y°= CIWMB California <br /> 181'(Nw04104) Survey Form - Page 1 Il - 1140593 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey <br /> __ BLUE ORBLACK <br /> less Profile Inspection Details <br /> I <br /> � Lk Inspection Type (Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: S(�n�(�(,(���/� C�(,(!1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> P S AOk f� <br /> Physical Address :) _ I V I �m �sZo�ta <br /> -- - -- <br /> / C Inspection Date I 1 / 0j / lJ <br /> zsi_10 z �� Time In Time Out <br /> Business Rep Title 0AM [ 0 AM <br /> ' V ® PM J 0 ® 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 /> s ' e6 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> D 0 Closed 0 Altered NJA <br /> GPS Latitude jf / 0 Hauler 0 Indoor <br /> D 0 Inactive 0 Truck //� <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 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 /> sed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> 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 FFI / M / M <br /> l0 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 f 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 /> �I C11V��tf �-�1�-- <br /> J 1 <br /> - I a v 10�UAIW_�ns cj wes- 4- c or)(.rn <br /> i Ck�t�fcsso t\Y)rfF�ler��(,�_ 10( <br /> ction Form Included: 0 / �y r-� <br /> Comments Included: 0 -- OBJ ���� `8 <br /> Business Rep's Signature Phone Number_ Inspe t is Signature Phone Number j <br /> • I� I 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect �/i r M P T012-13 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />