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Waste Tire Su' ,y & Inspection Report nspection Report Number <br /> PE; . <br /> State of California <br /> C,WMB <br /> 04/04) <br /> I 1 114- 0733 <br /> California Integrated Was eeManagement 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: 4 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SwIn Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> —�- C P Y Inspector <br /> 1 "YC cYV-CJ2. <br /> Physical Address <br /> 3 30 <br /> Inspection Date / 0 3 / <br /> Time In Time Out <br /> Business Rep Title n O AM Q AM <br /> /� Ci S 0 PM Q 0 3 O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q 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 Q Hauler Q Agriculture Q Shredder I& Other h A <br /> 1 U b Lc t Fcm/ <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> : <br /> V <br /> A HAULING AND MANIFEST REQUIREMENTS A ,; x,f, r,,,,,. <br /> ..... _— _.__...: -- Q Notice Of Violation Q Extension <br /> O 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 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 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 /> Q Q 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 1 Q 1 Other: § <br /> Comments <br /> _ ��r.�iv►.c� 1✓�Srv,-.tt.;Lam, �s►� � �fC.�S V103'C.G� <br /> r <br /> Inspection Form Included: Q <br /> Comments Included: ® — �vYYU�YO- Z' 6.4 �Z3 <br /> Business Rep's Signature Phone Number 4rtgpectoes Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. X ,IE.X Aq, 3 <br /> White Copy:CIWMB Yellow Copy Operator PinkCo : A <br />