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® Waste Tire Suk .ey & Inspection Report Inspection Report Number ■ <br /> State California Survey Form - Page 1 I 1 - 1140944 <br /> CIWMBB 181(New ) <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: 7 �� �y y� / ! Routine Q Re-inspection Q Referral Q Observation <br /> Local _ 7 If Referral,choose referral type(Fill one) <br /> r- 0 <br /> Identifier: CSL h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> �� /� - Z':"4 <br /> Physical Address E� f _s7e d's.0 <br /> Inspection Date /' � r✓ / // <br /> Time In Time Out <br /> Business Rep Title AM ly • AM <br /> "CP �T til <br /> ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 42 Cl (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � <br /> • Active I® Passenger ® Generator Q Outdoor <br /> GPS Latitude u <br /> aO Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned Q OTR ® End-Use ® Container <br /> Business Type (Fill all that apply) <br /> 0-New Tire Dealer Q 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 ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 DateM / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q j 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> — <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> Q O Other:,Q§ <br /> Comments -J�6'u�s� /1v��rC.z+��'Z7� `��-•.1` iG�GI*�_ d«.rt� �`'e--�2lC�r� ��-� i2.:�-fr...�; <br /> a—b- e 4"o-1 <br /> �-!"�`{1 ,��L. �y1�/.J/ J'— f�/i L•<<,%�'tG... �/9/- - <br /> 1e <br /> Inspection <br /> �IL},CG� '�✓'Pz�� � ` _�"� ��7 r���.. /�✓p 4f1 :)�l`�ct�"vy.�. __ <br /> Inspection Form Included:?BACK <br /> O�J-13 816� / /� _ �'� <br /> Comments Included: <br /> Iness Reps Slgnature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ! Correct:* Incorrect X �/. , XI A � 1 � 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Cop ■ <br />