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=_ Waste Tire Su. .y & Inspection ReporL Inspection Report Number <br /> F7i12 State of California <br /> CIWMB 161(New04104) Survey Form - Page 1 I 1 - 1127646 <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: 3 5 i o (C/ 7 J ! I tj 6 Routine Q Re-inspection Q Referral Q Observation <br /> � 11Local If Referral,choose referral type(Fill one) <br /> Identifier: l" ) <br /> A it��G Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> a I I <br /> Physical Address_ � � <br /> or 7 .1hC i <br /> Street cam` 5 <br /> �i Jcl 16 n / Inspection Date [ i <br /> Citv J tato ZIP'Code I Time In Time Out <br /> _ _. <br /> Business Re i <br /> p Title � ®AM Q AM <br /> C�J.._..__ IYa. �t JS Jam' !r —. PM 1_.. PM <br /> o j 3i o <br /> ► . <br /> ....__ '- - ._... .. ..... .. - OperationalStatus Tire Type Business Role Storage Type <br /> �jTire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q) Active Q Passenger Q Generator 0 Outdoor <br /> _.. O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 Q Other <br /> _.. ......._....___._..__ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / 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 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 /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments .s � � f�'.c� /y! / (� /���ic`�h prV <br /> lI Yt u � T T,fe�k.&rs .fal- -firs _re-1,1^cac1 r✓icy lsp , <br /> cz <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 82081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X J E X A M&P L E, 12 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />