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Waste Tire Su. .ay & Inspection Repor, Inspection Report Number ■ <br /> CIWMBCalifornia <br /> 81(New04/04) Surve Form - Pa e 1 I 1 - 1144048 <br /> California Integrated Waste Management Board Y <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J S 5 Lf V l Q Routine e Re-inspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: JG;yl �t C,ln IV1 & 0'l Xc_I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 56lc,( )6 roll,er-5 <br /> Physical Address <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AM Co AM <br /> ' D 0 P ` V © 0 P <br /> --- --- - -- -- -- - - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) -(Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ®Active Q Passenger- 4D Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair •Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - -_ ............._. ------ <br /> V li A HAULING AND MANIFEST REQUIREMENTS <br /> �Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> • Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date F�] <br /> / MILI / J <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB I r <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> r. <br /> Inspection Form Included: Q �j� lJ/ �yL <br /> Comments Included: *I - a <br /> - - _ <br /> Business 's Signa u Phone Number Insp t 's au <br /> Phone Number <br /> -_- 62081 <br /> INSTRUCTIONS ON BACK ', Correct: Incorrect: � � �,_ <br /> EDAM 1' 23 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop LEA ® ■ <br />