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M jj <br /> Waste Tire Sup ;y & Inspection Report ..rspection Report Number <br /> State of California <br /> B 181 04/04) <br /> Il - 1140843 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ® Z _ n Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: p,-, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> uc L �F <br /> Ira .�-,C . 9 d <br /> Physical dress <br /> J Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM / 0 AM <br /> Ll Y 0 PM ! PM <br /> — S Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 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 S Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <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 R <br /> -- - -1- - --- -- ----- --- -- - 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 m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 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 Generators ® In Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments / <br /> �Xkt,�7l.� i,+f 5��`c�r [^fin dS ��r.r� Cis✓u'�- `�Zr-C <br /> 14 <br /> Inspection Form Included: 0 <br /> Comments Included: ® <br /> Busl s Sig ature Phone Number/ �ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Corre t: Incorrect: v p� E1 111 2 � 62081 <br /> � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />