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[Xill Waste Tire Surv%& Inspection Report ection Report Number <br /> State of California <br /> CIWMB <br /> 04104) <br /> I 1 - 1127536 <br /> California lne grat dtWaseeManagementBoard 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: ' .� I® Routine Q Re-inspection O Referral O Observation <br /> Local �. v � � If Referral,choose referral type(Fill one) <br /> � <br /> Identifier: (ky) (-w' 1,Y) uo(� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P Y Inspector <br /> PhysicalAddress" r � Y, <br /> 0 l ci rc,q car Y1��co <br /> Inspection Date % O <br /> L.�-� ���\ Time In Time Out lJ <br /> Business Rep Title <br /> ®AM O AM <br /> 0 PM l 3 0 PM <br /> — - — - - - - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f <br /> 0 Active I Q Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — Q Planned 0 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair • Trucking Fleet 0 Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> A. :>HAUUNG AND MANIFEST REQUIREMENTS <br /> Q Notice Of.ViolationQ Extension <br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance.Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 forNOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years -- <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1`CIWMB Enforcement <br /> QO 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance `- No Violations <br /> Q Q Other: § <br /> Comments <br /> C41- 41 <br /> Ala oz) lctfi� c+ e�mee <br /> -- <br /> - <br /> Inspection Form Included: Q n g <br /> Comments Included: Q <br /> — - —,Business Rep's Si ature Phone Number Ins a tor' S' nature Phone Number <br /> INSTRUCTIONS ON BACK . } , ¢ p L]Ej 1112131 62081 <br /> White Copy CI Yellow Copy:Operator Pink Copy:LEA <br />