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Waste Tire Sueey & Inspection -Re,pInspection Report Number <br /> i� J <br /> State of California Survey Form - Page �' f 1 9 - 1006 3 91 <br /> CIWMB 187(New 114104) <br /> California Integrated Waste Management Board <br /> Part A- Survey NOV 2 8 203 BLUE OR BLACK INK PEN <br /> Business Profile A9 49403 Inspection Details <br /> TPID- q -3 <61 - I Inspection Type (Fill one) <br /> Site Suffix: 2 lS I t• I Q Routine ®Re-inspection Q Referral Q Observation <br /> Local ��, If Referral,choose referral type(Fill one) <br /> Identifier:, ..Sb4s� {� �={�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physi al Address <br /> Street <br /> �4^_ t l� ^52/S Inspection Date <br /> �C�Cli� GA_ `� I <br /> City State ZIP Code Time In Time Out <br /> Business Rep ^ Title ®AM O AM <br /> lzQ] <br /> d O PM �Z ' ® 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 /> I I ' 7 �I� ® Active 0 Passenger ® Generator ® Outdoor <br /> j D Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® Dismantler Q Tire Derived Fuel <br /> Q 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 I I <br /> Part.B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation ® 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 /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB f <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities --__ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> ® 1 O 1 Omer: § — R G 1+283 4- M i^or�..? 1>�`7fK. �.(i f f ►.a_ <br /> Comments <br /> he,.-o„►�- -�'r-�s_ GTL. Y�u;n-�s �p-� v-�;�� _ <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Sign re Phone Number I ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: I EJXJ AIMI P I L I El 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ®. <br />