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ajs Inspection Report Number <br /> Waste Tire Su :y & Inspection Reporo <br /> State of California <br /> CWMB grated 1(New04/04) Survey Form - Page 1 Il - 1140694 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / a 3 O / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5CkAl)Trk C6-Ax <br /> r� �,, f �y I0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name `^'-`^ 9 Inspected By Inspector <br /> -V1 i C>_ R( , t,v i CLAQ S �fAc <br /> j Physical Address - L7 <br /> i <br /> Inspection Date U Z � � O <br /> s�-vcictvr LA �2t� <br /> Time In Time Out <br /> Business Rep Title 40 AM ® AM <br /> [ 0 S D QPM I J QPM <br /> — J�`.tiYlR s �u � UP Sk�x�Yl/I f 0'rOperational 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 /> f / 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> 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 ® 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 /> I _ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> — <br /> V AHAULING 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 m / m / m <br /> 0 I 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 <br /> In Compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> Y�fr6 sVKrsc + IUw -- -r vet f' GA J- - LCr, <br /> a( Inv <br /> Inspection Form <br /> Included: QI <br /> j I o�P $ Oto <br /> Business 11p1s Signature Phone Number Inspector's �, ,tur�e Phone Number <br /> - — <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X .X A, M ',,-1 2131 <br /> White Copy CIWMB Yellow Copy Operator Pink Copy: E <br />