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�i Waste Tire -.�rvey & Inspection Repc Inspection Report Number ■ <br /> State of California <br /> CIWMB 04104) <br /> I 1 - 114 3 6 0 7 <br /> California Ine grat dfWas eeManagement Board Survey Form - Page 1 <br /> Part_A- Survey _ —_ - - - - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local // If Referral,choose referral type(Fill one) <br /> Identifier: , �(� � (-Ol/1�i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> CJ&S FvAnc�"�v� <br /> Physical Address <br /> 5C00 ZE . FrP_vn prl;4 <br /> C[530,5 <br /> l <br /> Inspection Date 3 1 fl <br /> LJ Time In Time Out <br /> Business Rep Title 0 AM � � � �1 QO PM 0 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 /> i v ® Active 0 Passenger 0 Generator •Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Hauler 0 Indoor <br /> O <br /> 0 Inactive ® 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 ® 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 AI HAULING AND MANIFEST REQUIREMENTS <br /> I <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 / Ffl / <br /> 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 <br /> Inspection Form Included: 0 Q <br /> Comments Included: ® ---- �(�-- V _l 3�_s� �- - - - --- o20�r- 7� _ <br /> B siness Rep's Signature Phone Number Ins aor' iS' nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ! � 11- 12 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: ® ■ <br />