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Waste Tire Sus „ay & Inspection Report Inspection Report Number ■ <br /> SIC State of CaliforniaCMB <br /> California lntegrated81(ew04104mentBoard Survey Form - Page 1 1T 1 <br /> .+ 1127910 <br /> Part A- Survey _ K <br /> BLUE R INK PEN <br /> Business Profile Inspection Details <br /> TPID- t O 1 I _ I Inspection Type (Fill one) <br /> Site suffix: l I <br /> ® Routine Q Re-inspection Q Referral Q Observation � <br /> Local 1 If Referral,choose referral type(Fill one) <br /> e <br /> Identifier: an J(�A �C1(1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> -� <br /> -- <br /> Inspected By Inspector <br /> t <br /> r '-V i a' So 3li - 0 Ben E5wo o <br /> Physical Address <br /> 1 <br /> �SuS f"C'ZIisko666r) (A�i - <br /> Inspection Date I I <br /> Time In Time Out � <br /> Business Rep Title 0 AM 0 AM <br /> I I a ' a 5 0P QPM <br /> l�T�i►r i S S+Oje, m <br /> ---- �J --- ---- - v - - ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger 4j Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use ®Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> F-- -- <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q 0 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 Q Other: § �1 <br /> Comments �1�/`1 f1R► 1G� c.' Ll r c�_1L ( (.? <br /> Qr) *-le- 0 ow nl� wwz�' '04azV_ <br /> Inspection Form �nc <br /> ncluded: Q1 v <br /> Comments luded: u <br /> - - <br /> Bu ' ,,,Rep's Signature Phone Number Inspec s Signature Phone Number <br /> - -- �� 62081 <br /> INSTRUCTIONS ON BACK Correct:is Incorrect X % A � 1_`L`'I <br /> ■ - - - - - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y: <br />