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Waste Tire Sut „ey & Inspection Report nspection Report Number <br /> CIWMB81California <br /> CIWMB Survey Form - Page 1 I 1 - 1144003 <br /> California Integrated Waste Management Board Y <br /> Part A-Survey__ - BLUE OR BLACK INK PE_N <br /> Business Profile Inspection Details <br /> TPID- Inspection r - O Inspection Type (Fill one) <br /> Site Suffix: �j J ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(A (� J On C1 LCL-N (OtL4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 --- - <br /> Inspected By Inspector <br /> L. (Ay 6% D a 3 r <br /> Physical Addr 9 - l <br /> Inspection Date 5 � 1 <br /> Time In Time Out <br /> Business Rep Title ^ 0 :AM Y I Q AM <br /> S l-� to PM <br /> - <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 /> > > QST 0 Active 0 Passenger a Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive Ila 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 ® Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility L ENFORCEMENT STATUS <br /> V A 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 <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 1 I <br /> U (1,u rel rl S( c �c2 I rfuLA (�f l 5 l CI <br /> W- V 110 A+f v.nS O f Q'f taus 67 (,uP to n. - - - - - <br /> Inspection Form Included: DSI �Signature <br /> Comments Included: I/Yy <br /> -C J <br /> �I <br /> B,iness Phone Number �nspef. ign.tu, Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink 50y <br />