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Inspection Report Number <br /> Waste Tire y & Inspection Rep <br /> State of California <br /> CIWMB 181 04/04) <br /> I 1 - 11413 4 5 <br /> California Integrated Was eeManagement Board Survey Form — Page 1 <br /> Part A- Surve) _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- l Inspection Type (Fill one) <br /> Site Suffix: ` )) <br /> - - - C�' � 1 1. � Routine Q Re-inspection Q Referral Q Observation <br /> Local ` ./g �-; If Referral,choose referral type(Fill one) <br /> Identifier: ��.� J �� l� I� (✓► I ' ' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> _ P Y Inspector <br /> Physical Address U - ^TZJd[^ �� it Aarn b�i1� <br /> Inspection Date q9, Time In Time Out <br /> Business Rep p Titlel 0 AM Q AM <br /> �� f✓�l/ 0 PM B PM <br /> Operational Status Tire Type 1 Business Role Storage Type <br /> f i /r) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f <br /> II.JJ 0 Active ® Passenger le Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 00 TR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FTI / [I] / [Il <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 1 <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 14 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 j In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 1 LI&A_ <br /> - �2 c�o Wil- YlC� O <br /> Inspection Form Included: OI <br /> Comments Included: r-- - - - —�- - - �- --- - <br /> Q,Business Rep's Si Vature Phone Number In ct Si nature Phone Number <br /> INSTRUCTIONS ON BACK Cor cncorrect: X �, IE X M4P — S ] 62081 <br /> WhiteCopy IWYellow Copy:Operator Pink Copy:LEA <br />