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Waste Tire vu. vey & Inspection Rept. ` Inspection Report Number ■ <br /> CIWMB81California <br /> (New 04104) Survey Form Pa(('��e 1 Il - 1127700 <br /> California Integrated Waste Management Board - `�J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- • 7 5 ® ' Inspection Type (Fill one) - - <br /> Site Suffix: t 1@ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localr^ If Referral,choose referral type(Fill one) <br /> Identifier: Su(� JQa�u,�Il Wu � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ne <br /> Physic <br /> aress 3 5 - I o <br /> 5\S f0fk <br /> Inspection Date <br /> 11.411 `iV V Time In Time Out <br /> Business Rep Tiittlle1 I O O AM 0 AM <br /> �eJ\ 0,. P I LI�CJ� . 0 PM O (D PM <br /> -- - - - -- -A- --- --- Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) j(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active & Passenger • Generator 0 Outdoor <br /> D 0 Closed 0 Altered 1114 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive i • Truck <br /> Longitude ---- -� 0 --I 0---__-- 0 End-Use 0 Container <br /> g Planned OTR <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 <br /> � ENFORCEMENTSTATUS <br /> — - __- - - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q 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 <br /> 0 I 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / M <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 /> Comments 10 11 1 1 ` u <br /> 1,ns1✓ I.r _4\ S —-�c �1n�. o_l.0w fl was, <br /> (VD--� tky,O T1s <br /> Nc�e_.•. ti, ra�ilik �i��Llh�S U�� k�� ��r 0711-SiTC_�11?�-__Gl.�ll/` di3 _�SGI,_�, <br /> Inspection Form Included: Q ,/�-� _ ✓G6 y <br /> Comments Included: Q, - - -E% '� �� . 7( <br /> - - - - - -- <br /> Business Rep's Signature Phone Number Inspect nature hone Number j <br /> INSTRUCTIONS ON BACK Correct: Incorrect �/ , E X A p; 1 2 3 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink C py:L A <br />