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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> CIWMB 81California <br /> Survey Form - Page 1 I - 1140954 <br /> California Integrated Waste Management Board J <br /> -t A- Survey BLUE OR BLACK INK PEN <br /> ;iness Profile Inspection Details <br /> r'ID- Q Inspection Type (Fill one) <br /> Site Suffix: [ �` - <br /> S J U I Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local t r.` If Referral,choose referral type(Fill one) <br /> Identifier: S G,n J oil0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> S qtr r a. t IA,rn� e,r _ <br /> Physical Address Hcae" <br /> 3`75 W - 'an /-lv , IJ <br /> qO `1y[��_V^ CA Isz)b3 Inspection Date I l 1 Q <br /> Time In Time Outo <br /> Business Rep Title 0 AM 0 AM <br /> 1 I 3 5 0 PM � � 5 � PM <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 /> Al 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altere n7 N,,1 <br /> GPS Latitude 9lA 0 Hauler"" 0 Indoor A <br /> O 0 Inactive 0 Truck <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 Q 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 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tiros 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 1 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / m / m <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 /> 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 <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments : nAi AI U? Ce. l l fC. r In'r'�C!'Tl2rrv-� UQ 7t)311% CJt11 <br /> -na <br /> NO <br /> ,,ection Form Included: Q <br /> Comments Included: �Oq.QY-3- 7.7�-7 ad -3178 <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect. . r A ,fly p 62081 <br /> _ X I j <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />