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Waste Tire Survey & Inspection Report inspection Report Number <br /> CIWMB 81'fornia <br /> (New 04/04) Survey Form - Paige 1 Il - 1143628 <br /> California Integrated Waste Management Board J J <br /> Part_A_- Survey -_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` � � � � C � - O 1 Inspection Type (Fill one) <br /> Site Suffix: ` 7 l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r ' If Referral,choose referral type(Fill one) <br /> Identifier: Sun J oo_vA;fl (C7L4,(�'"\ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J <br /> Inspected By Inspector <br /> J DoR�es . 1 0 <br /> Physical Address 9 03 <br /> ).0��� <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title u 0 AM (� 0 AM <br /> PM 1 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' S- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 18Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered I <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 ! 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 1n' �— I FOrN - <br /> C10 V'vblc�'�(�sus o s (M M-s ZI co rq c<<1 n-_- <br /> Inspection Form Included: 041 <br /> Comments Included: <br /> Business Re s Signat e v Phone Number Inspect 's Signature one Number <br /> - - - - <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect X 11213162081 <br /> ■ - - - - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :LE <br />