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- �92100�0�15 <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> i State B California I 1 108692 1 <br /> California Integrated,Wase81 eMa agement Board SCIWMurvey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ,r, -1 � � i � I p� � � 1 - Lo <br /> 1 Inspection Type (Fill one) <br /> Site Suffix: Il 1�I v ', -1 ` S Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: U,0 zco) 410 4Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1, Inspected By Inspector <br /> ��).Cum lkV, <br /> Physical Address 1 1 &I aca <br /> X33 Vv S Avg-. --- <br /> Street O <br /> SX3 Inspection DateC4 <br /> CA q <br /> City <br /> t) 1D, ` ate LIP Code I Time In Time Out <br /> Business Rep TitleI�11 <br /> 0 AM 0 AM <br /> i � 5J�® PM ; �I ' � � � 0 � QPM <br /> -- CiOperational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (V (Fill.one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger If Generator Q Outdoor <br /> O Q Closed Q Altered �]/� <br /> GPS Latitude Q Hauler Q Indoor r-/" <br /> -'O Q Inactive Q Truck <br /> Longitude Q End-Use Q ContainerQ Planned OTR <br /> Business Type (Fill all that apply) FO r�� <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 I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other AD�a/,Y 1►'� <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING W N Ell 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 / 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 DC7) <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 I C-IWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-ttse Facilities <br /> Q 0. 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> Inspection Form Included: <br /> 0 -Oro <br /> — 37 <br /> Comments Included: Q 7��-Q-��— <br /> Business Rep's Signature Phone Number Inspe s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: R A M P L E . 1 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />