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;iWaste Tire Joey & Ins ection Re of L Inspection Report Number <br /> see of CaliforniaClWMB 1181 I 1w 04/04) - 1140740 <br /> California Integrated Waste eManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � - © � Inspection Type (Fill one) <br /> Site Suffix: 1 ft Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQ,Y1 l/1 J ��u�} 'A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> --du. J <br /> Business or Facility Name <br /> \- Inspected By Inspector <br /> �en n�t� �1 t.CC�o Co_ u� i� 3 - C ], <br /> Physical Address J I Q &n <br /> �&k D A Inspection Date q / 5 1 0 <br /> Time In Time Out <br /> Business Rep Title 01. //--�� O AM `` 4% AM <br /> kk MC-In f V O O PM----1 d O PM <br /> - .. O - ----- - ----- -- - -- -- - W -- - - Operational Status) Tire Type Business Role I Storage Type <br /> Tire Count (Whole/PTE) I, C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> -t Active 40 Passenger Generator ® Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 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 ® 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 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 / 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: § <br /> Comments <br /> Inspection Form Included: 01 / A6 <br /> Comments Included: / r�i "' <br /> ® Business Reps Slynature Phone Number Inspec is Signature ` f�6ne Number <br /> - <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect X E K A P0V 1112[3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: E ■ <br />