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Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> ii State of California <br /> CIW04/04) <br /> California Integrated Was eB 181eManagement Board Survey Form - Page 1 I 1. 1086-99 <br /> Part A- Survey' BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: O _l <br /> _ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ� J U C�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name UInspected By Inspector <br /> hP ysTcal 'A"ddress n S <br /> /603 S . <br /> Street <br /> Inspection Date <br /> city G State ZIP Cod Time In Time Out <br /> Bus�,Rep Title Ii Q AM Q AM <br /> --I-1 • L� ® PM 7/] <br /> �" J ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> -==_O Q Inactive ®Truck <br /> Longitude - I Q Planned ®OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 10Trucking Fleet ®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 IIIENEORZEMENT STATUS <br /> V A HAULING V N Dl MANIFEST REQUIREMENTS <br /> Q Notice -i in 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 <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 EXn <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 t GIWMB 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: §{� _1- <br /> Comments rllOtiZ1��Cy C.(MC- OYlA(LL C e�f�G3✓LC� TI(-t� <br /> /a k-d <br /> Inspection Form Included: Q <br /> Comments Included: Q �R y- Y InaoSBusi �ure <br /> Phone Number Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK C rre Incorrect: EVAIMI-PICIE1 1 2 3 <br /> White Cop :Cl M Yellow Copy:Operator Pink Copy:LEA <br />