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lrr _ Waste Tire Su & Ins inspection Re-port Report"Number <br /> SE6&o. State of � � '' <br /> Su`rveyForm -.Page1 i. 8 - 1 006366 <br /> CIWMB 181 Californiaf New 04/04) <br /> y�a California Integrated Waste Management Board <br /> Survey BLUE OR BLACK INK PEN J <br /> Business Profile Inspection Details <br /> TPID- I Inspection Type (Fill one) <br /> Site Suffix: 1 - V Q Routine O Re-inspection O Referral O Observation <br />'r Local C,- If Referral,choose referral type(Fill one) <br /> Identifier: ��.� �. O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name --- <br /> Inspected By Inspector <br /> // !_ ` � r./ 'nom I <br /> Physical Address — f r � ' <br /> Street <br /> r.•`--. Inspection Date <br />�. City State Zlp Code Time In Time Out <br /> I Business Rep Title O AM / O AM <br /> [ailQPM i <br /> tf `� �j <br /> t, @'DPM <br /> O <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)O Active Passenger Generator r <br /> i <br /> 9 �' � Outdoor <br /> O O Closed O Altered <br /> GPS Latitude m.• O Hauler O Indoor <br /> O <br /> O Inactive O Truck <br /> Longitude — O Planned O'OTR O End-Use O Container <br /> J <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> (D,+Used Tire Dealer O Auto Body O Car Dealer O Collection. O Crumb Rubber <br /> i <br /> O Service Station O Hauler O Agriculture- O Shredder. O Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> FV7,, A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O. 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date r- M'04, 1 <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> (' O 1.4 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> 1 1.'r c 4�t /J k'S tn�� �Y1C. 1'�,r-, —= vrIsnc,�rti <br /> Inspection Form Included: <br /> Comments Included: ) 1 ' —' 1!" ' -" <br /> _ - <br /> Business Rep's Signature_ — Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ,\/,( JFE14-61A1rh�r. P .L ] 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />