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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State B 81(Ne is Survey Form - Page .1 11 - 108830- <br /> California 7 <br /> CMfMa 187(New 04104) ` Y ry <br /> Integrated Waste Management Board y <br /> Part A-Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I<? 0Routine QRe-inspection <br /> Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: y� 1 � ,uLg4�`7/ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address A.- <br /> jNLJ <br /> Street <br /> [L�_) Inspection Date <br /> --i J Time In Time Out <br /> rh/ :State 17 Coda <br /> Business Rep Title O AM O AM <br /> '31 : 1 <br /> TPM ; J ' ' 1 O ® 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/ s o <br /> ®Active Q Passenger ® Generator • Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - i I , ; Q Planned •OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q 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 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 HAULING AND M-ANI ES QUIREMENTS 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. C-ompliance Deadline <br /> QQ PRC§42956-Registration/Decal in Vehicle 7 <br /> O Q• 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 (Req fired for NOV or EX7) <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 <br /> See, <br /> —��j12a) .J �Q P <br /> Inspection Form Included: O - <br /> Comments Included: <br /> `1J,e,H .2617 JK370 arc l- Y68- 7 <br /> Busl ess Rep's na re Phone Number 41nct es Si a re. Phone Number <br /> INSTRUCTIONS ON BACK o ect: neorrect: )CAMP L 1 j Z 3 62081 <br /> White Cop .CIW Yellow Copy.Operator Pink Copy.LEA <br />