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y & Inspection Report inspection ReportNumberWaste Tire Su <br /> CIWMB 181 I1 - 1140701 <br /> State of California <br /> California lntegratdWasteManagement Board Survey Form ew 04/04) - Page 1 <br /> Part A-Survey_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ ( Inspection Type (Fill one) <br /> Site Suffix: .7 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: SCkC) J C)"LLI 1 Cum�%- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> (01'e-4 W t','k%.r r ' 1'1. p <br /> Physical Address 3 I 0 I C S Cc�T ra <br /> 3 lc�S Gln er <br /> O C A qSZ d S Inspection Date S 3 ` 3 <br /> Time In Time Out <br /> Business Rep 1,� 1 Title •AM 1 , • AM <br /> `��'� <br /> ��---1�akc,'I ,C.U(J►�L. S�LYG�t'�S�j� ulLt� I I � U QPM 1 � "1 U QPM <br /> -- -- u 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altere � )A <br /> GPS Latitude P]-h 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other �i ULA zr S 4s 1 `az v— <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 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 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E_ M <br /> 0 0 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 0 Referred i CIWMB Enforcement <br /> 0 0 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 0 Other: § -� <br /> Comments n 1 <br /> l)Ir <br /> ' c_ n "' /1"1 Un'1 Ll I'� --. L kP - <br /> (�0�� (� U1y1aVTlt�S b1 c tfa�.S � �U116-A <br /> Ll0 e �- <br /> Inspection Form Included: 0Iy <br /> Comments Included: /V `.__ _.\'�rwl�"'.-C( �-.1 - -3� l�. <br /> g_ I Business Rep's Signature Phone Number Inspe is Signature __ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I X6 h� 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />