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Waste Tire SLft. y & Inspection Report Inspection Report Number <br /> State CIWMB <br /> f 81(Nrni Survey Form - Page 1 1 9 - 1 0 7 9 3 8 8 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / 5 / O Inspection Type (Fill one) <br /> Site Suffix: - 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: / j� <br /> ..✓� t:/D�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector _ <br /> A <br /> Physical Address 3 - Sari 4307 i Jul ��' <br /> Inspection Date 0 �j <br /> ��� •i1�Os7 C47- 9S^� <br /> Time In Time Out <br /> Business Rep Title 0 AM AM <br /> 0 PM 0 PM <br /> K-� / / <br /> _ " 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 0 Generator (9 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 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 /> -- <br /> V I A `HAULING AND MANIFEST REQUIREMENTS <br /> - ---- Q Notice Of Violation Q Exten`sl <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 <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB _ r <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 114 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 n Compliance No Violations <br /> Q Q Other: § <br /> L <br /> Comments ti r`^�Cs�t �,�J f� �2 rfo�.��✓7 tl LVr.I; <br /> Inspection Form Included: QI _ -7-°9 <br /> Comments Included: — ---- <br /> Business Re Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK <br /> e /4 9 ns A p L l E t t' 2 3 62081 <br /> ,`. <br /> White Cop CI Yellow Copy:Operator ' Pink Copy:LEA <br />