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= Waste Tire Sur .y & Inspection Report ispection Report Number <br /> Stateof California I 1 - 1143455 <br /> 04/04) <br /> California lntgratdWaseB 181eManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID ' S _ O I Inspection Type (Fill one) <br /> Site Suffix: • Routine O Re-inspection O Referral O Observation <br /> jLocala.� If Referral,choose referral type(Fill one) <br /> V1 Identifier: " Toc�C ; (S _- <br /> , _- J Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name IIJJ <br /> Inspected By Inspector <br /> Physical Address 3 Cf — C7 <br /> �w,avrcly .bcx�ficw <br /> Inspection Date © 16 2 ) C, <br /> s cc�o r,� CA 1S'3 2 v <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> So ' PM � 9 4 0 PM <br /> Operational Status <br /> Fill one only) Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> ( y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I � � i <br /> ® Active Q Passenger ® Generator ® Outdoor <br /> o <br /> O Closed Q Altered <br /> GPS Latitude i 0 Hauler fndoor <br /> D Q Inactive ® Truck <br /> Longitude — - Q Planned J_Q OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Government Q Retreader Q 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 0 Hauler 0 Agriculture Q Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -—- <br /> V A 'HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires l <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 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 O 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 /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> O O 'Other: § <br /> Comments <br /> -- � �c tns�r.�h=uv cm-� ?�;.s eL���- Lie--�'!l�✓:.-� ��- <br /> �tv d - <br /> Ale ay 4,yeaf <br /> Inspection Form Included: Q. <br /> Comments Included: Q — - -- - N- <br /> Business Rep's Signature Phone u ber Inspector's Signalure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E`X ,�;` , { E' 1 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: EA <br />