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x <br /> Waste Tire S...rvey & Inspection Repo. . Inspection Report Number ■ <br /> CIWMBCalifornia <br /> 11(New04104) Survey Form - Paige 1 I 1 - 1143671 <br /> California Integrated Waste Management Board ! J <br /> I"t_A-Survey -BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> I PID- ii Inspection Type (Fill one) <br /> Site Suffix: l 19, S U l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ol 2 _ <br /> Physical Address 3 9 <br /> 1500co r�► \� <br /> Inspection Date <br /> �� C,� CA '15S76- Time In �7 Time Out <br /> Business Rep Title O AM O AM <br /> O PM O 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 /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> O ®'Closed 0 Altered Ni <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive ® 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 ® 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 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 1 V j q I 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 Date M 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 F_XT) <br /> 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 �r In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> ,..,pection Form Included: 0 <br /> Comments Included: C1QC'ICiVr✓�YJ Y 7� <br /> Business Rep's Signature Phone Number 1pct"_ PhoneNumber <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct. incorrect X i! E <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />