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z Waste Tire Su ;y & Inspection Report Inspection Report Number <br /> i3Alf State of California <br /> CfWMB <br /> 1(New04104) Survey Form - Page 1 I 1 - 1140904 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 C, 1 0 Routine O Re-inspection 0 Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �. w 6� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit O Other <br /> Business or Facility Name, <br /> — Inspected By Inspector <br /> Physical Address alwla"p -3 <br /> 3 /1/ 7 /�r . — <br /> oZ 3 f <br /> Inspection Date 1 / O <br /> S�GktC �� �l'SaO� <br /> Time In Time Out <br /> Business Rep f� Title O AM 0 AM <br /> Via <br /> a aZ 0 j ® PM O 112y �S ® PM <br /> l�' <br /> Operational StatusTire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) C 2 1(Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> l 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude <br /> GPS — - 0 Hauler 0 Indoor <br /> O O Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR O 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 /> 11 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 /> VA; L HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 1 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 / <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m m m <br /> 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 I O,Referred I CIWMB Enforcement <br /> O O 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 0 in Compliance No Violations <br /> OO Other: § <br /> Comments <br /> -1 5W_e./_7Z4- -7441.-r .-ate - - <br /> Inspection Form Included: O <br /> Comments Included: - Rep's <br /> i Business tg_ature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Gref� nCOICf «� � XjkAOILIEL <br /> 62081 <br /> ' ':'.:� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Covt <br />