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L ,a Waste Tire Su. ,ey & Inspection Report :. Inspection Report Number <br /> State B CaliforniaCIWI 1 1127678 <br /> 04104) <br /> California IntegraM d Was eeManagement Board Survey Form - Page 1 <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5 1 40 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 0 � /l�G►Y�W� <br /> RD-7 &3 . <br /> MInspection Date I � a <br /> � � Time In Time Out <br /> Business Rep TitleO AM f O AM <br /> �- � 3_� ® PM f ' C) � ®PM <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 /> f C2 ®Active ® Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS _Latitude . Hauler I Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ®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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS 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 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 /> 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: § <br /> Comments �f,���n{� 1'►IS�C-.L�J��ff,.L�t`'C.) �',2' 711 f.3---���,G.�. <br /> iInspection Form Included: Q <br /> Comments Included: ® -J - — - - -- —-- -- — -- - --- <br /> 5�6 <br /> - Business ep's ignat re Pho a Number I p s ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct_* Incorrect: �/: � 1 2}31 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y:L 0 <br />