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Waste Tire Su y & Inspection Report nspection Report Number <br /> StCaliforniaSurvey Form - Page 1 I 1 - 1127615 <br /> CWMB 1 (NewIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A_Survey_- - __ -_ - BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details - <br /> TPID- / / - / Inspection Type (Fill one) <br /> Site Suffix: I / ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C_ If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address - / 0 <br /> Q-� ` dace - - - - - <br /> ��I Inspection Date O Q' � C) 5- <br /> Time In U Time Out / <br /> Business Rep Title ,a 0 AM Q AM <br /> ca la/&vN I�, U --- -� -® PM 2 : ,3 O -® PM <br /> I <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 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> i <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station -0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> _-- - ......................_ _... 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 I 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 li 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred!CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsio In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments !vJ fB1'l Ai,<z OU"t <br /> W i so),__w -T-✓-,e does fes- o`SILI�s - Vic?s <br /> 4tk-e5 Ace, <br /> /J C) ui s �ofe�. NC) �a� �ir� s 5 trec� 6 <br /> Inspection Form Included: 0. <br /> I 2 � 67 <br /> Comments Included: -- -- - - -- %) /�-- - -- Signa— - - -- -- - <br /> - D,B siness Rep's Si ture hone Number Inspector' ture Phone Number <br /> X �M���� 62081 <br /> INSTRUCTIONS ON BACK ' Corr ct: Incorrect: J` � ��X �,N� P �.j� I � � <br /> ■ White Cory:C Wl C Yellow Copy:Operator Pink Copy:LEA <br /> f <br />