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j <br /> Waste Tire Susi & Inspection Reportalnspection Report Number <br /> ® State of California Y p ,■ <br /> Mini Survey Form - Page 1 <br /> I1 - 1088353 <br /> cIWMB,s,(New oaroa> y <br /> California Integrated Waste Management Board - <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> ,Business Profile " a, Inspect►on Details <br /> TPID- <br /> 0 Routine Type (Fill ) <br /> Site Suffix0Re-inspection 0 Referral (M Observation <br /> rInspection�� <br /> Local -- ' — _ If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint (f) Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address—� } IJ O ( h y" ({ <br /> (Doul . <br /> (- --._— — Inspection Date <br /> /,Few--J t a c kC'-k; <br /> h�F ti� State ZIP Code� Time In Time Out j <br /> , ............,.,- <br /> Business Rep Title j 1 (� a AM f j O AM <br /> 0 PM PM <br /> t rc-. ._ --- i- r - -- <br /> .- -----I � ir <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> „ k (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Jv 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> GPS 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 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 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 <br /> 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 /> 0 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/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 /> Com`7ents f C r Tf 11,1 i` t 4t i1 ��J( �-Yi�L t tl { }`•.!'' <br /> 1r, �`/ t:11 / +�c't it 1./jE.� <br /> J <br /> iT t o <br /> t. <br /> Inspection Form Included: 0 t <br /> Comments Included: Q g f <br /> Business Rep's Signature Phone Number <br /> g Inspector' 'Si nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® incorrect: X ,� � �a ; � 3 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />