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Waste Tire Afey & Inspection Re omelnspection Report Number <br /> State of California I - 1143711 <br /> CIWMB ew 04/04) <br /> California Integrated'W81 aste Management Board Survey Form - Page 1 <br /> PartA-Survey - _ - __— _ _BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- j Q �'f 1 �/ ) - O f Inspection Type (Fill one) <br /> Site Suffix: l l t l ( ® Routine Q Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sao0 CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name <br /> / tL Inspected By Inspector <br /> bs M G, <br /> Physical Address �) I - 4 <br /> � 01;o N(AMM4 lc>+� <br /> V �` r^ � �� Inspection Date <br /> S+ <br /> ,'(nom` (q CA 15Time In Time Out 1 111 <br /> Business Rep Title _ O AM L� O AM�- -� A PM - -- -� e PM <br /> - - - -- "-- ---- --- — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5 O O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ® Generator • Outdoor <br /> O Q Closed �Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR 0 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 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler 0 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 10 Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> O i 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 j <br /> (Required for NOV or EXT) <br /> O O !,I 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 O Other: § <br /> Comments (kY)t/1- - <br /> Inspection Form Included: <br /> Comments Included: y� t <br /> tPrGo <br /> rV <br /> Phone Number Inspe is Signature -Phone Number <br /> INSTRUCTIONS ON Incorrect � � e A M► p L � y 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />