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Inspection Report Number <br /> Waste Tire Survey & Inspection Report <br /> k2CIWMB State California9 - 1140700 <br /> grated 1(New04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Suryq� _ _ _ BLUE__OR BLACKINK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 O _ O Inspection Type (Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Locali If Referral,choose referral type(Fill one) <br /> Identifier: �u� J OC tAl N C0'tAn1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Udl ' s Cv�cr���. �n 3 � ) C� <br /> Physical �Ad ress Es � <br /> �I_I_�vU f3 `, "l J A c s�Z o Inspection Date S I '1 3 <br /> `� Time In Time Out 111 <br /> Business Rep 1 l Title/�� 1 AM G S AM <br /> � V O O PM F O Q O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) l p (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I ® Active ® Passenger 4j Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned ® OTR <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 0 Other Cc�r �k Uii0.% <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 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 Date m / m / m <br /> 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 ® In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments F?vv�1`nc� G _ /H u., 10A AA ,n <br /> 0 AA <br /> i <br /> Inspection Form Included: Q V - 'n 1 (���{ <br /> Comments Included: �I- - - - )_Aw-`�1 - - - - - --6taij--I -j��ness Rep's Si natu(2111 <br /> Phone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK ! Correct: Incorrect: ( E A 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink CA:L <br />