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0904S05002i <br /> eee- <br /> Waste Tire Survey $ Inspection Report Inspection Report Number ■ <br /> i� State CfwB California T 1 0^^^^^ <br /> California lntegratedt81 Wast+e Management Board Survey Form ow 0,4104) - Page 1 1 VX VX L lL•l Sl[7 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: O -- _ O Q Routine Q Re-inspection ®Referral Q Observation <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier: C �_Vw C j, Q CHP ®CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> — o_Qcl_I _1 T f�-e�S iW , 5H - ' i � <br /> Ph sic Ad ress 3 � O � V Q,V'l,�_ <br /> I ! 3 a 5 _ S, Com_ �r s�f-• I <br /> Street <br /> Seo —n Inspection Date <br /> city State ZIP Corse <br /> i fl/H1 7 Time In Time Out 1 <br /> Business Rep TitleQ AM O AM <br /> I Q ®PM [:O7L I ®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 /> . f' / I✓ O ®Active ®Passenger ®Generator ®Outdoor <br /> I I O .Q Closed Q Altered <br /> GPS <br /> Latitude <br /> .10 Hauler Q Indoor <br /> tI - -I—. -------- Q Inactive Q Truck <br /> Q Planned Q OTR -® <br /> Longitude _ ! I End-Use Q Container <br /> 9 <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 ®Collection Q Crumb Rubber <br /> Q Service Station ®_Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS ®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 b 3 / © /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 ®Referred I 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: § _ /� j <br /> Comments Ci wm B (U Q✓V are OF I Q t-k o f <br /> CTL Q v i-Fv in WT/V1 S databAse—for jh i S h A,yJP1` <br /> /_'�2 cei 1/ '' 0 9 . � 4;P V ��s i f' 1 ;S do "e . S i fe uVa.s <br /> F-0�c,�c� have vev- ! SO <br /> Inspection Form Included:Q />���I��^ ' r� <br /> Comments Included:® Y o L� <br /> Buss ss Ignatu Phone Number Insp ctoes Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK Co rest: ncorrect: AMPL <br /> I62081 <br /> EXE; ] 23 ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />