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PPIP <br /> i-= Waste Tire ley & Inspection Rept Inspection Report Number <br /> rr;g <br /> EEI State California Survey Form - Page 1 Il - 1143639 <br /> CIWMBB 781(New 04/04) y g <br /> California Integrated Waste Management Board <br /> Part A-Sum BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` I Inspection Type (Fill one) <br /> Site Suffix: C/f_ Q e Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: says -- 0-sy-1— Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name V- <br /> „r Inspected By Inspector <br /> 1 %r <br /> Physics Address ' <br /> CHs- s. Cherc)6ee_ Z_a. - <br /> g5dlo Inspection Date J Z- <br /> ) <br /> Time In Time Out.. <br /> Business Rep/} � <br /> Title O AM O AM <br /> S /-1 IC."1IanI &r ..O PM � � � ® PM <br /> C�.LLAOperational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> le Active * Passenger Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS 0 Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Lo End-Use ® Container <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 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 Q 1 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q 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 /> 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 Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ®I r«c .2lr1e'�t.-..ice � <br /> Business Rep's Signature Phone Number In p tor' naturelee�l <br /> Phone Number <br /> -- - <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect X I�! � p 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:LEA ® ■ <br />