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■ i Waste Tire Su. :ey & Inspection Repo, a Inspection Report NumberState ■ <br /> esu <br /> �. <br /> CIWMB <br /> f 81(New <br /> survey Form - Page 1 I 1 - 1127721 <br /> CIWMB 181(New nage g <br /> California Integrated Waste Management Board "�' <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O I Inspection Type (Fill one) <br /> Site Suffix: ` 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: S JUf,I LIlr1 Cf�tf1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> i� 7 k�'s (e,S _ <br /> Physical Adjess 3 - U I (moi n CSLA 6 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep TitleO AM / Q AM <br /> ' � � PM PM <br /> -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (� <br /> 9 Active ® Passenger 41 Generator • Outdoor <br /> Latitude <br /> O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q 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 /> ® 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 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 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 O -- - - <br /> 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 <br /> ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § (,� <br /> Comments (Aa Q- J � n JJ(4� 1. <br /> �r ���� kaAk, <br /> Inspection Form Included: Q <br /> 17 <br /> Comments Included: Q :uf,, p'Ag6nV�m�M <br /> - - �V `?0 1 <br /> -- <br /> ma Pone Number �In pe is Si naturehone Number <br /> INSTRUCTIONS ON BACK [Correct:0 In X �i "'� ,M Q E 62081 <br /> ■ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop .LE <br />