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Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> 11i1- State of California <br /> CIWMB131(Now 04104) Survey Form - Page 1 i 7 - 0 0 6 7 8 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile (��`1�'��} �{ inspection Details <br /> TPID- i � � � i „ J "7 <br /> �+ I+�_f O � Inspection Type (Fill one) <br /> Site Suffix: l l Ii3 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q -'� �-Y� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Q� <br /> Business or facility Name a �/�,� Inspected By Inspector <br /> .�►')+zr rVIO�,,�,t_/"lr^^- P.41 V 41(eslrc <br /> Physical Address �l <br /> 100O Et � I <br /> Street / ' O <br /> ` Inspection Date <br /> ID <br /> 1 f <br /> 2+tic (�-�- P-; C0. � 3I <br /> City State ZIP Code Time In Time Out <br /> Business Rep J ) Title J� <br /> EE m 0 PM m - m 0 PM <br /> _ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) . I I �I C) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ® Active Q Passenger ® Generator Q Outdoor <br /> I _T—�I 10 Q Closed Q Altered <br /> Latitude <br /> G PS 1 - ® Hauler Q Indoor <br /> L _ _ d Q Inactive ® Truck <br /> Lon ttude - i Q Planned Q OTR Q End-Use ® Container <br /> 9 — � . —' <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ' A I HAULING AND MANIFEST REQUIREMENTS <br /> 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. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m ! m I m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 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 /> O('vjYl e- 1 & F0 110 Vj ,a,�,L 5 no 1 K--S�G� �S <br /> t <br /> i s a. r►�ob,i_I� rna:�w-�e ,�✓' -f"�+�.c,� c�a <br /> P qr', <br /> a ` w�, tr2frw� Pc ic-GAsf ��cter 0Pcg Pce AV-a& <br /> Inspection Form Included: Q per" kn <br /> Comments Included: - , 3�3-ZmbePhone NuIns ctor sature Phone Number <br /> INSTRUCTIONS BACK [Correct: Incorrect: q I E XNI A P L E111273 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />