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t <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California Il - 1140563 <br /> CIWMBB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Pert A-Survey - --- --_- - - -_ .. - --- -_ - --_-_ -. -_ - BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> j r'ID- _ O I Inspection Type (Fill one) <br /> Site Suffix: l Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �O CUu n� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> SI\\JQ-( C'- (10 finn <br /> Physical Address 3 l 0 1 �en Et toh <br /> dal( -7-7 5 � �,c�ccs,� I�v��v� �!� w <br /> �rQ v �� ����� Inspection Date L 1 Ill <br /> � 1 <br /> Time In Time Out <br /> Business Rep -- II II Title I O C 0 AM ® AM <br /> V1Ll,l J OPM O 0 P <br /> rr <br /> 1Q 9-ro- ► rk� mss;ink --- --- --—- -- -- - - -- <br /> -- - — - --- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> flJor 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Closed Altered JJ��)� ) yy�� <br /> GPS Latitude 0 / 0 HaL r/A 0 Indoo��l`!r <br /> O 0 Inactive 0 Truc A <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 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 0 Agriculture 0 Shredder IS Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1 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 Datem / <br /> / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB i <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 I <br /> A\I\L- towl_r� __WTAS <br /> Nn J_aAlam a (,_a� t� o r,<Qro <br /> �__dection Form Included: 0 ` <br /> I Comments Included: (4 <br /> Business Reps Signature Phorie Number_- Inspect s Signature Phone Number -I <br /> INSTRUCTIONS ON BACK Correct Incorrect L ! 62081 <br /> - - - -- - a1L� P; i3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />