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Waste Tire Su ;y & Inspection Repore Inspection Report Number <br /> State of California <br /> CWMB <br /> 1(New04104) Survey Form - Page 1 I 1 - 1140839 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- t Inspection Type (Fill one) <br /> Site Suffix: / z 5- y d ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S� Gr.�. <br /> ' <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - - - - -- <br /> Inspected By Inspector <br /> Physical Address <br /> Al. vV C f.,k <br /> [ Inspection Date <br /> �cl�fur� � ls�o Y <br /> Time In Time Out <br /> Bess Rep Title /� � � Q Q AM � � Q AM <br /> V <br /> ® PM ® PM <br /> - Operational Status Tire Type I 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 /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered I <br /> GPS Latitude = - , Q Hauler 0-Indoor - <br /> O Q Inactive Q Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q 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 HAULING AND MANIFEST REQUIREMENTS <br /> -- - ---- —i Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB / <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred]CIWMB Enforcement <br /> k <br /> Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance No Violations <br /> Q Q Other: - <br /> Comments <br /> i� f/K�-�✓r! a4w <br /> ction Form Included: 0 <br /> InsPeComments Included: ® - �/!" �---- -- -- - - -L ZE3Gl)L16 f -04.Z� <br /> Business Reps 'Signature nspector s Signa ure Phone Number <br /> INSTRUCTIONS ON BACK Cbrre �� "( �66'�� I ... .....� t..�_��_��� 62081 <br /> _ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LE <br />