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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State B SUM/p Form - Page 1 <br /> CIWMB CaliforniaCal fNew 04/04) Survey�iy g I 1 - 1143594 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> A-Survey <br /> iness Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: 1 5 ® 10 Routine Q Re-inspection Q Referral Q Observation <br /> Local , If Referral,choose referral type(Fill one) <br /> 04U1Identifier: S�{� 04U1n �(�LI ' '1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name `! Inspected By Inspector <br /> Cec R �o`c tut, e_ L of q - I I Qe n �ssofto <br /> Physical Addre <br /> Inspection Date V <br /> Sncl � CPt �5a15 <br /> Time In Time Out <br /> Business Rep Title I O AM O AM <br /> * 1 "10 . PM a ' 3, v(1 <br /> A n(N Ge c -C., /� vs�eu� -- <br /> a PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> Q Active Q Passenger 0 Generator Q Outdoor <br /> GPS Latitude O ® Closed Q AltereN/� Q Hauler Q Indoor'/ <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 End-Use Q Container <br /> Rosiness Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> (� <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other ,5I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 0 PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q 0 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 O -- -- <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q 0 Other: § <br /> Comments -10', <br /> N� Li oA aki clod, O S aSt'a5 of (,On gjrn. <br /> Inspection Form Included: Q <br /> Comments Included: • Rep'sNOumbIerBusiness Si nature Phone Number ns e <br /> � <br /> - -- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X IV/ I E.X{ A P L- Er $ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA In <br />