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-° Waste Tire Su. _ ey & Inspection Repot, Inspection Report NumberState of ■ <br /> CIWMB 181ffo(N woo/04) SurVe Form - Pauye 1 I 1 - 1127911 <br /> California Integrated Waste Management Board Y J <br /> Part A_.-_S u rvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r-� Inspection Type (Fill one) <br /> Site Suffix: 3 / 0 1 O I ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S Ck,0 36 Lt'%n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business oor Facility Name Inspected By Inspector <br /> 1il, I �C�I <br /> Physical Address l O 1 1�en Es id <br /> Inspection Date I q <br /> �ST1 b C. L� o C A 5 ao� ` <br /> Time In Time Out <br /> Business Rep Tittlle� 0 AM 0 AM <br /> ( <br /> � ` '1 1 0 PM 0 0 PM <br /> -- - - d n --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active ® Passenger ® Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ®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 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 <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. I Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date T / 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 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments � �.t�e N 1 10 (y�,�-t'tl_�RC1(�' (�� F _ll S MtC_ (AA0)(/� <br /> '\1c"o���w�- +v�-fit s 6�o 'ec� ' <br /> ,c3 n.s o Ct taus (()cuA_r n . --- - <br /> Inspection Form Included: Q 2C) �,J C� <br /> Comments Included: C),I "��$� �.r. <br /> �(��J `(A- 0 <br /> Business Rep's Signature Phone Number �nsature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect: ,� P r 62081 <br /> XtJ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: <br />