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Waste Tire Sur ,,ey & Inspection Repor t, Inspection Report Number ■ <br /> CIWMe81California <br /> CIWMB Survey Form - Page 1 Il 1143955 <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: 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(A��(� � (`� O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �00k EX Q mss , �,n c,- C, ,1 <br /> Physical Address 1 l �/ �Q(� ESL �(3 <br /> Inspection Date 5 � d v7 6 <br /> Time In Time Out <br /> Business Rep Title I 0 0 AM 0 0 O AM U O PM v `' PM <br /> -- -- -- -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 (Fill one only) I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i Active Q Passenger 0 Generator 0 Outdoor <br /> 0 O Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O Q Inactive 9 Truck <br /> Longitude j 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A IHAULING AND MANIFEST REQUIREMENTS <br /> i i ''10Notice Of Violation � Extension <br /> O O <br /> 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® / Mi- <br /> 0 <br /> 1 b <br /> ® 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 114 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 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 /> ® O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § _ <br /> Comments <br /> J <br /> o r, 1� CCS �buln�., - C -s V1CINe_A_1 Cvi -0 - <br /> I <br /> ,Inspection Form Included: Ali���' CQOI)9 W-317 <br /> Comments Included: <br /> usiness Rep's re Phone Number Inspe is Signature_ Phone Number <br /> - - . <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I. j JE XIA ��, -- 1112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />