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Waste Tire Su. „ey & Inspection Report Inspection Report Number <br /> ==g State of California <br /> B Il - 1143743 <br /> California Integrat dtWaste Management Board Survey Form - Page 1 <br /> 'art A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- © � � � s � � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `� If Referral,choose referral type(Fill one) <br /> Identifier: 1� 5 ���� Ceti 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physics dress l TT i �►' M1►h�t/CL <br /> 1q35- E 44,`-1 l rr-xp <br /> Z Inspection Date <br /> / J <br /> cJkrop 8533 0 Time In Time Out <br /> Business Rep Title &AM ® AM <br /> 6 l� Q PM 0 PM <br /> Operational Status, Tire Type 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 /> 0 Active 0 Passenger 0 Generator ®Outdoor <br /> Latitude le Closed 0 Altered <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill ail that apply) <br /> 0 New Tire Dealer 0 Auto Repair IS 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 <br /> I <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ; ENFORCEMENT_ STATUS <br /> V j A I HAULING AND MANIFEST REQUIREMENTS <br /> Registration and Transport ort of Tires 10 Notice Of Violation 0 Extension <br /> O 0 PRC§42951 -Waste Tire Hauler Re <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 i 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 /> Comments <br /> II <br /> C0iWI27 eWA CSC <br /> J <br /> Inspection Form Included: 0 <br /> Comments Included: <br /> mess aArSignature Phone NumberAEA <br /> i ature Phone Number <br /> INSTRUCTIONS O / <br /> BACK ! Correct � Incorrect I �' � � � �l f � � 62os1 <br /> N <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />