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Waste Tire SAey & Inspection Repo* Inspection Report Number <br /> 'rni• California <br /> CIWMB 81st(New Mana a Survey Form - Page 1 1 1 - 1 0 7 9 2 2 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey_- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / ,/ n / Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: c�,�}/J Al 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address &U I �/ � r kA40£ _/ <br /> 22.4C) C cw"i (.ox- <br /> / QC Inspection Date D y Z 9 08 <br /> �� ! Time In / Time Out <br /> Business Rep Title 0 AM 0 AM <br /> -�!'! e�f31�/. -c DGt�n1 C 0 PM 0 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 /> (Y (/ 0 Active 0 Passenger f Generator 0 Outdoor <br /> D 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 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 0 Other Ago,,,- <br /> a <br /> rt B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1ENFORCEMENTSTATUS <br /> V i A HAULING AND MANIFEST REQUIREMENTS <br /> 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 5 3 © Q <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 EXT) <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/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 0 to Compliance - No Violations <br /> 0 0 Other: § -- ---- -- -------- - <br /> Comments <br /> i <br /> a s Yctc[�• -1�s�t t-LckL�- - i— -�A -wGs -t - <br /> jt.4. � - -�,Q,IP�c _�4Q�1/�eia.0 •Caa-t s_ �D <br /> q. <br /> Inspection Form Included: , <br /> 0Comments Included: DI'-" ` - - ------ --- -- pac�__�-=all, <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X No/ (E X I A,MFPFL I E 1 1112 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />