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= Waste Tire ;..irvey & Inspection RepL.. t Inspection Report Number ■ <br /> State of California I 1 - 1140971 <br /> CIWMB 181( e ) <br /> California Integrated WasttManagement <br /> Waste Management Board Survey Form - Page 1 <br /> p-q A--Survey___ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> i PID- Q Inspection Type (Fill one) <br /> Site Suffix: ` © J L/ L Routine Q Re-inspection Q Referral Q Observation <br /> Local (� ,� If Referral,choose referral type(Fill one) <br /> Identifier: 136-11 ' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - ---- -- <br /> Business or Facility Name Inspected By Inspector <br /> hCG -be sick-, !,,v%c, C� - <br /> Physical Address f 1 ) � � , <br /> Inspection Date <br /> �63C4-1 l v J <br /> Time In Time Out <br /> Business Rep Title (/D� r SAM r + ) AM <br /> MCA <br /> �� V Li 0 O PM ( I ! � Q PM <br /> MCISGl r! - .t'1 f* - ky%cave i1 --- - - -- - - -- <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 /> Q Active Q Passenger 0 Generator Q Outdoor <br /> t7o 0 Closed Q Altered IV,14 <br /> GPS Latitude A//,4 Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other fcnv�.t.�,Y— <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> Q PRC§ �Q Notice Of Violation Q Extension <br /> 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 M / 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 /> 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 114 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: § <br /> Comments <br /> ,pection Form Included: Qi 7 <br /> d� G 44 <br /> Comments Included: W < - -- - <br /> Business Rep's Signature Phone Number In cEo 's ature - Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect I ^ ,q M pI 6208 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />