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M = Waste Tire Sup vey & Inspection Report "`Inspection Report Number ■ <br /> i" CIWMB California 81(New 04/04) Survey Form Page 1 I 1 - 1143496 <br /> California Integrated Waste Management Board Y - J <br /> Part-A-_Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � (q � _ ,p, 1 Inspection Type (Fill one) <br /> Site Suffix: l b V I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �' 1 ` If Referral,choose referral type(Fill one) <br /> Identifier: S(4I J Qm k1 n 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> (� n � 0_ <br /> Physica AddreLss <br /> Inspection Date <br /> � un��cam. CA �533'1 <br /> Time In Time Out <br /> Business Rep Title O AM l O AM <br /> ' 5 0 PM 1 (k PM <br /> iyOak V_rou,!!� ?I P-&i&r)� <br /> - -- - -- -— Operational Status Tire Type Business RoleStorage Type <br /> I / <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> '�^/ <br /> r 0 Active Passenger ® Generator Outdoor <br /> Latitude 0 0 Closed 0 Altered <br /> GPS 0 Hauler Indoor <br /> 0 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 y� <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other �0�1'St+tFor' VE'�►G4 1�Iq �. <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O 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 / m / 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 /> n 1 <br /> Comments tC o ��l¢,—UJ�S SC•�Ll��Q,(i�I CLQ asr(_QA, 1_A:N_-t- <br /> t <br /> by Io 0S% oraACkc, (i t x x) ce.r,n <br /> ,Inspection Form Included: <br /> O <br /> Comments Included: �- o Z39 <br /> �i Business Rep's Signature Phone Number Inspec is Signatur _ _ Phone Number <br /> / 1,41 <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �/ >t 1 2131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:LE <br />