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Inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> State of California 04/04) Survey Form - Page 1 11 - 1127484 <br /> California Integrated Waste Management Board ! �+ <br /> Part A-Survey - __- -- _- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - - - - - — <br /> TPID- (l 1 Inspection Type (Fill one) <br /> Site Suffix: l 3 O v O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: 5�� �o��3 111 )n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> -'Qe1 12;0 �cS� Q� 1�e,� �I.4nc, <br /> Physical Address <br /> tofu <br /> �^ ()(� Inspection Date U I O <br /> 1 ehb ` b� - `^'" Time In Time Out <br /> Business Rep Title I O O AM I O AM <br /> r t PM J ® PM <br /> b ��115-� ��— Operational Status 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 /> 5 ® Active Q Passenger e Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <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 t l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �( S�TJ}�klon �IC1+ <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q 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 Q 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 /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 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 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities -- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> Q Q Other: § <br /> Comments n [-% Gli e, dl Wj ( <br /> n - -- <br /> o '• � 1�C1 � _ c_S �u,nn� �ti' c. � _ 'r iS'E" 's �U,u�Cf. <br /> Inspection Form Included: QV'l /C� <br /> Comments Included: _ --C4V) D 7,1 <br /> Usines R 's ure Phone Number Inspec is Signatur JJ Phone Number <br /> 6208 <br /> INSTRUCTIONS 0 K Correct:6 Incorrect. ? MI <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE ® ■ <br />