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=E Inspection Report Number <br /> Waste Tire S_ �ey & Inspection Repc <br /> State of California <br /> 04/04) <br /> 11 <br /> California integrated Wast B 181eManagement Board Survey Form - Page 1 Il 1127477 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: / f ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �( 1 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> 4s(iVarVIld �Z'(1­> _yress I l l� Ay <br /> A bo • <br /> Inspection Date C 0 <br /> Time In Time Out <br /> Business Rep Title J <br /> O PM ( , O PM <br /> - ---- - --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a ®Active Q Passenger ® Generator O Outdoor <br /> O O Closed O Altered <br /> GPS Latitude Q Hauler Indoor <br /> O O Inactive 0 Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q 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 /> O Service Station O Hauler O Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility LENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 10 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 /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <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 Q 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 O Other: § <br /> Comments K f?t%t1�> <br /> Jgdah6_yl VP f�&Iyme_eA CYI <br /> /V/C2 16,h/2W3 Q-y- 4 J <br /> ,Inspection Form Included: Q >444� /2/ 02 <br /> Iz- <br /> Comments Included: Q -- - 74J <br /> Bu a ess Rep's Signature Phone Number I ec 4lgn ure Phone Number <br /> -- _ - <br /> INSTRUCTIONS ON BACK Correct Incorrect i }ai 62081 <br /> i <br /> White Copy:CIWMB Yellow Copy:Operator Pink py: <br />