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Waste Tire Sat Bey & Inspection Report Inspection Report Number <br /> CIWMB811fornia <br /> (New 04/04) Survey Form - Page 1 I 1 - 1143703 <br /> California Integrated Waste Management Board <br /> Part A- Survey -__ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- © I Inspection Type (Fill one) <br /> Site Suffix: l 1 tJ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Localn �• If Referral,choose referral type(Fill one) <br /> Identifier: Qt' J cul Wl.l� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A- 1 Nie5It- T;re, ScrV; cc- - 1 C� <br /> Physical Address 3 Rcn E ' <br /> Inspection Date 1 � , <br /> S� � c A s Time In Time Out <br /> Business Rep Title 0 AM0 AM <br /> aU 0 PM 3 -1 ® PM <br /> �Il t���1� Gore Ul��e r --- -- -- -- <br /> - - - - -� <br /> Operational Status Tire Type j Business Role Storage Type <br /> Tire Count(Whole/PTE) i I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I • Active Passenger Generator ® Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler e Indoor <br /> O Q Inactive 40 Truck � <br /> Longitude - ! Q Planned Q OTR Q End Use Container <br /> Business Type (Fill all that apply) <br /> ® New Dealer Q Auto Repair •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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> Q Q Other: § <br /> Comments `�n l'1( lt,�Gl�LC �j)G t 1L1 f - <br /> 0 16 w i-l1 v3 to - n Ol c- - --- - - - - - -- - <br /> Inspection Form Included: Q <br /> ✓ �- . -�'���� 075-/ <br /> Comments Included: . - - — <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �+ �/! I�T�� 1112131_ - 62081 <br /> `_, � � � I? L � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />