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Waste Tire Sui ,iey & Inspection Report - Inspection Report Number <br /> �o= State of California <br /> C,WMB <br /> 181 04104) <br /> I 1 — 1143495 <br /> California Integrated WasteManagementBoard Survey Form - Page 1 <br /> Part A- Survey -_ BLUE OR BLACK INK PEN_ <br /> Business Profile -Inspection Details <br /> TPID- Inspection Type (F <br /> ill one) <br /> Site Suffix: 15V <br /> - -- - <br /> (0 Routine Q Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SG(1 JQr,�u,C1 � O CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 070V� (oa-l')v U_ 1XA01 <br /> Physical Address 3 c( 1 0 <br /> ^,� m�` G�� c n A is;�� Inspection Date � � � � <br /> `�� � 1 <br /> }1 Time In Time Out <br /> Business Rep Title 5 O AM V Q AM <br /> PM J 0 PM <br /> -- <br /> -- - - - -- -- ---- Operational Status Tire Type Business RoleStorage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 1 <br /> Active Q Passenger ® Generator 0 Outdoor <br /> D ® Closed O Altered <br /> GPS Latitude O Hauler Indoor <br /> 0 O Inactive 0 Truck <br /> Longitude - 0 Planned OTR Q End-Usej Q Container <br /> Business Type (Fill all that apply) Fosl7,l��� <br /> O New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber Lj, <br /> Q Service Station Q Hauler O Agriculture Q Shredder I* Other �os�L' ` 52�V j ce— <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility j ENFORCEMENT STATUS <br /> VI <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O O 114 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> A In Compliance - No Violations <br /> Q I 0 Other: § <br /> Comments QUVy�1'aL UJGLS'I2 <br /> 'Inspection Form Included: Q <br /> 0uy-4 v'Ks�g� e�IJu��-31'7 <br /> Comments Included: �,•% - - - - - - - - <br /> Business Rep's Signature Phone Number Inspec is Signature Phone Number <br /> Business - Si <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. Xi 1 2 3, 62081 <br /> ■ ® ■ <br /> - - -- - --- <br /> White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />