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® Waste Tire �y & Inspection Repinspection Report Number ■ <br /> State of 81(Nw04/04) Surve Form - Pa�uye 1 I 1 - 1127723 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I^ _ Inspection Type (Fill one) <br /> Site Suffix: 3 l5� (Q ® 1 Routine Q Re-inspection Q Referral Q Observation <br /> Localn 1 If Referral,choose referral type(Fill one) <br /> Identifier: - �` 1 � ��(� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> W'k <br /> Inspected By Inspector <br /> 0)� 0� 0r'f) _ <br /> Physical Address 31 V I Rtn C-3cob- <br /> 11sp, 1 Vv . C, usver W w - - - - - <br /> Inspection Date <br /> A SA <br /> Time In Time Out <br /> Business Rep Title 1 z O AM f� Q AM <br /> (�� J o 9 PM V O PM <br /> 17(XI u� "l- Wat�a - - - - - -- <br /> - - - - - --- - -- --Operational Status j 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 /> t 40 Active Q Passenger Generator 11 Q Outdoor <br /> D Q Closed Q Altered NIA <br /> GP$ Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned (�® OTR o End-Use Q Container <br /> Business Type (Fill all that apply) FO s1�� <br /> Q New Tire Dealer Q Auto Repair Q 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 C <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other ICAor 50. f JUL- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> o 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 o PRC§42956-Registration/Decal in Vehicle <br /> oI o 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB j <br /> Q o 14 CCR§ 18459.2.1,-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q o 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 Q Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> o 0 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> S In Compliance - No Violations <br /> o o Other: § � <br /> Comments ��-61L V r\ ��f,` n IAQQ <br /> Inspection Form Included: L <br /> Comments Included: Q - z��u�$-�`-79Business Rep's Sign ure Phone Number ec i <br /> Insps SignPhone <br /> ature Number <br /> - ---- <br /> —/- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X !�'�% VI X A 11213620811 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Ctpl/ <br /> ■ <br />