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rJI Waste Tire Sui .ay & Inspection Report Inspection Report Number ■ <br /> CIWMB81'fornia <br /> (New 04/04) Surve Form - Pa[�e 1 Il - 1140561 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey —_-_- _ _ BLUE OR BLACK INK PEN <br /> Business Profile 1 Inspection Details <br /> TPID- cl / - O Inspection Type (Fill one) <br /> Site Suffix: 7 lQ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: S(,(t1 L�1l1 C >n� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Tvctn �WI.��oU 3 - o <br /> ,Physical Address SAO«AAA... <br /> Inspection Date 5 <br /> Tc, C A Qs3�� I <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> Q PM Q PM <br /> - - - --- - —- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /x (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> SCJ 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered Aj lz �f <br /> GPS Latitude IVJ� 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR o 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j A HAULING AND MANIFEST REQUIREMENTS <br /> o Notice Of Violation Q 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 /> FFI / M / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 0 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 -- -- ------- <br /> 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 kjdX4C_ �1�r\ Vim' on 4�1' (/`,L(�g oLPAR 43 <br /> t t <br /> _. N oy ►u1.�4,v.�s o5 c�le�.s c�"_ c.�nc�u-�� -- <br /> tQ k% _act' c,� ()afvnic, oA ou)NA;P, it 1539W01' dox`bl& <br /> Inspection Form Included. ' <br /> p o'I S <br /> Comments Included. Q - - --- (�: � <br /> Business Rep's Signature Phone Number &1npjt.Vr'ss Signature Phone Number <br /> _ - - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> --- ,�y � x <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy/LEA © ■ <br />