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Waste Tire .ju► _ ay & Inspection Rep.,d-t Inspection Report Number <br /> State of California <br /> CIWMB 181 04/04) <br /> I 1 - 112 7 9 4 3 <br /> California lnegratdWaseeManagement Board Survey Form - Page 1 <br /> PartA- Survey _- BLUE OR BLACK INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: CA J to O 40 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(�(� JQtt uI nCom, O CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> cakTCu,o� 3Q o l <br /> Physical Address <br /> I (001A S . <br /> 5t6ck�o^ C)A It Inspection Date I O (0l <br /> Time In Time Out <br /> Business Rep Title C) AM AM <br /> v 5 O PM 1 l "1 ,.J Q PM <br /> - - --- - ----- —-g - Operational Status Tire Type Business Role ' Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active . Passenger Generator 1 Q Outdoor <br /> Latitude D O Closed I Q Altered <br /> aue <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned OTR O End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet • Government Q Retreader Q Dismantler O 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 - O 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 Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 / <br /> O 14 CCR§18459.1 -Tire Program ID Number from CIWMB I I h <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 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 /> O O Other: § <br /> Comments %Xkl 112. <br /> - 11 ew�nq_u�cls o l yccl_ �� --- -- —-— <br /> &2. CvMcwn6 F©rA- <br /> llnspection Form Included: QI <br /> Comments Included. <br /> �JCr <br /> Business Rep's Signature Phone Number Inspe&VTV <br /> nature ` one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect X "� E X A M I 111213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ■ <br />