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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of s;ifo ni oa,oa, 11 — 1143456 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey_ ___.___ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- '3 - ® � Inspection Type (Fill one) <br /> Site Suffix: ` `� ` l Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> Identifier: 5 n Qat(uki/, �U 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I J Inspected By Inspector <br /> T, ;Oni? rt SrnA11 �oflls _ <br /> Physical Address ( , a�� C3zoa <br /> ��✓f CA Q S�O� Inspection Date �( ( ( I v <br /> 1 Time In u Time Out <br /> Business Rep Title O AM ^ O AM <br /> 5 PM fii PM <br /> S0svi off -- - - -- - -- <br /> -- ---- - --- — --- -� --- - - Operational Status Tire Type Business Role <br /> Tire Count(Whole/PTE) 5 Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> S Active Q Passenger ®Generator (f Outdoor <br /> 0 0 Closed Q Altered <br /> GPS Latitude Q Hauler 10 Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude - Q Planned 40 OTR Q End-Use I Q Container <br /> Business Type (Fill all that apply) <br /> 0 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 <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder (a Other C113n4414,c�y„ 61L,;?, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility f ENFORCEMENT STATUS <br /> V A i <br /> HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 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 /> 0 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> O O - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> nn 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> o Q Other: § <br /> Comments �b ��� � �Je lr �tTl'l�n �ePkOjtrl� Q�"`►'1 '� e A c��2, <br /> i p\A)'0n-, mt�COWS Cj)()CQf i)- <br /> Inspection Form Included: Q Q` )1 V <br /> Comments Included: 4 <br /> usmess Rep Ignatur. Phone Number Inspect s Signa re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect l�j �/i ! 62081 <br /> f2 3 <br /> ■ White-Copp --- --- — ® ■ <br /> y:CIWMB Yellow Copy:Operator Pink Cop <br />