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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CWMa81(New <br /> 1'forni a04/04) Survey Form - Page 1 I1 - 1088097 <br /> California Integrated Waste Management Board Y g <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> ,Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 6 g © ( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `- If Referral•choose referral type(Fill one) <br /> Identifier: C� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> /l 1 Q533 p Inspection Date 9 / I �' / 0 G <br /> Time In Time Out <br /> Business Rep Title 0 AM L I / 0 AM <br /> Ja�nn,� S, <br /> 3 ' D O ®PM l L L/ 0 PM <br /> —Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r 0 Active 0 Passenger •Generator .Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive In Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- 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 EXT) <br /> 10 0 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 f 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 in Compliance - No Violations <br /> 0 0 Other. § - - --- <br /> comments Piov me. "ec-bz�,n 6cme_ ori 8\,,J . ctnu ,J/Yk� <br /> Was �110� c <br /> Inspection Form Included:0 <br /> Comments Inc luded:0 -- <br /> sinlessRep's Sign are. Phone Number Inspect 's Si t Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C ect:� Incorrect:X V E X AMPLE 1 2 3 <br /> ■ - t r - .. Pink Copy:LEA ® ■ <br />