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Waste Tire Survey & Inspection Report inspection Report Number <br /> State CIWMB California I 1 - 114 3 7 5 4 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-_Survey__ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O I Inspection Type (Fill one) <br /> Site Suffix: • Routine Q Re-inspection Q Referral Q Observation <br /> Local �' ` If Referral,choose referral type(Fill one) <br /> Identifier: �(�(� JOCJ-Gorr(� ��n�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityNamel Inspected By Inspector <br /> Cc)4&/ ' r lJl Ct1 S °� U Ben eln ESC40 <br /> Physical—Address 1 <br /> ncaoS Inspection Date I <br /> Time In Time Out <br /> Business Rep Title 0 AM S 0 AM <br /> 0 PM 3 � `� � PM <br /> - --- ---— Operational Status Tire Type Business Role Storage Type <br /> n <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> "l t <br /> i® Active •Passenger S Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude � Q Hauler Indoor <br /> O Q Inactive It Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <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 ® Other r.. m <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS--- <br /> iv <br /> TATUSI V I A 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 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 (Required for NOV or EXT) <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 it In Compliance - No Violations <br /> Q Q Other: § <br /> Comments n11i 41 �a �� 1 /ln , AALIL� kej <br /> 1�C3YCS� t I 4G15 ►�c_ Uf "IIIC� I Ol1'Y�l tS [L . <br /> Inspection Form Included: 65,Z-7$3 rf) <br /> Comments Included: AI - <br /> Busine s Signature Phone Number Inspe ors Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:6 Incorrect: �/� E X A 13 620811 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink CV L ® ■ <br />