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Waste Tire Sui . .:y & Inspection Report Inspection Report Number ■ <br /> 5i1ZS� CIWMB 81California <br /> (New 04/04) Surve Form - Pa/uye 1 I 1 - 1143994 <br /> California Integrated Waste Management Board Y J <br /> 'art A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � � � � _ O I Inspection Type (Fill one) i <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /� ]] If Referral,choose referral type(Fill one) <br /> Identifier: SUn J alti u l(� Coupa 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Stb(40 �� Cin-E�r- _ I e o�'r <br /> Physical Address EC �l�l.) <br /> G��q S_ q - <br /> 5h <br /> � GA 15DOG <br /> Inspection Date � / ) � � I <br /> Time In Time Out <br /> Business Rep Title ` . AM 10 AM <br /> 0 PM 0 PM <br /> ` Jb 'af"ub�0 Y`'y f 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 41 Generator 0 Outdoor <br /> j� <br /> Latitude O ® Closed 0 Altered I0 <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive * Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other Av ItS41,01) SC-f rl' <br /> 1,(j;,S <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> 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 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: § ,-\ n^ �1 !� <br /> Comments D � t ���....._U�(& <br /> rw <br /> N )',ol�,a ons Ins u Cc--s n� wc,cn <br /> Inspection Form Included: 0 - q <br /> Comments Included. <br /> smess Rep's Signature Phone Number Inspe r s Signature - Phone Number <br /> INSTRUCTIONS ON BACK Correct �- Incorrect: , 1 (� iVII IF C1 (_I F 12131 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink op A �� ■ <br />