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® Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMB81'fornia <br /> (New 04/04) Surve Form - Pa e 1 I 1 - 1140564 <br /> California Integrated Waste Management Board Y <br /> "-rt A- Survey <br /> BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> I PID- � 1 � � � � _ � l Inspection Type (Fill one) <br /> Site Suffix: IVnt U I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: �(�O e - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0_t, con4J UJI10n 31 - 0 1 SCO 6 <br /> Physical Address �Cn E <br /> 1I , I � , o <br /> 530 1 <br /> Inspection Date 1 <br /> Time In Time Out <br /> Business Rep Title 1 QO b AM <br /> Q 0 (DAM <br /> Ll <br /> 14p. �or �.�}. O PM 1 PM <br /> a�t 1fw.... — — --LuJ�LSTt }--� <br /> - Operational Status Tire Type Business Role Storage Type <br /> „( <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �yv) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> D 0 Closed Q Altered /♦77/A NJ� <br /> GPS Latitude �l� Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude – Q Planned Q 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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber I _ _ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other 5>'(/IUILe•. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § 1 �,,f__ <br /> Comments �s L qe jsZ r_ eS_1�� — q , LLS k Z <br /> - N � io1 ' oI_1�fs cl_s efn- <br /> .spection Form -317p�� <br /> Included: QI� maIA 'A <br /> �,A(ae jq& <br /> fi <br /> Comments Included. 91 <br /> Business Rep's Signature Phone Number Inspe is Signature _ _ Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect ( e XIAMIPJLIEI 111213 <br /> 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />