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Waste Tire Sou&y & Inspecti®n Rep®r*Inspection Report Number <br /> 3S $ State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1141234 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID i l n E Inspection yp _( ) <br /> j� �jI I <br /> Type Fill one <br /> Site Suffix ' �J -/` � � Q Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: <br /> (� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> N` � <br /> Physical AddressRc n <br /> .. t <br /> {� Y <br /> suee <br /> Inspection Date , I ( <br /> s <br /> ... . <br /> ��---�- Time In Time Out <br /> Sfaffa �iF'C;>de <br /> Business Rep Title r AM j r O AM <br /> 1 � <br /> O PM _. ._._.._ ....._ O PM <br /> I _ � - t `- .- OerationaI Status Tire Tye Business Role Storage Type <br /> The Count(Whole/PTE) j (Fill one only) (Fill all that apply){ (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger, Q Generator Q Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude q Q Hauler Q indoor <br /> C Q Inactive QTruek <br /> Longitude — l Q Planned CYil Q End-Use U 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q --- — Q Notice Of Violation Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Dr:,;ale <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m M / m <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 Q In Compliance - No Violations <br /> Q Q 'Other: § <br /> t ' <br /> Comments N ALL <br /> „t S <br /> otAA� <br /> Inspection Form Included: Q, <br /> Comments Included: O <br /> Business Rep's Signature PtstsneNuroiaer Inspector's Signature Phone Nt.:rr€ier <br /> r��_20 <br /> � € 31 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ,i A IAA P� I <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA IM <br />