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Waste Tire St, ley & Inspection Repot Inspection Report Number <br /> State of CaliforniaCWMB 04/04) <br /> California Integra[dtWas eeManagement Board Survey Form - Page 1 T 1 <br /> 11 1141326 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile 'Inspection Details <br /> TPID- f � � ' r � � - � I Inspection Type (Fill one) <br /> Site Suffix: ` b 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalI �, If Referral,choose referral type(Fill one) <br /> Identifier: 5 O-A J o n (00A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �\�Ql � Co Inspected By Inspector <br /> L <br /> Physical Address c <br /> Inspection Date <br /> •}1- Time In Time Out �/ J <br /> Business Rep Title0 AM 0 AM <br /> t ' I 3 O 0 PM I � � � PM <br /> Nocc <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 /> f • Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® 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 1l'_ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ! Other K ; J 11iu1�'j4l �1ST1�Vbr <br /> llJJ """"ii <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 7-A i HAULING AND MANIFEST REQUIREMENTS <br /> 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 M / FTI / M <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 f CIWMB Enforcement <br /> Q O 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 In Compliance - No Violations <br /> Q 1 O Other: § <br /> Comments 1(1A \a\ 060-a 101A 0oe - mA\1'6 c6fe, arlA 0 1 t <br /> M \1\1 '6ao n S a r CEJ w t, CA (00ky <br /> -- <br /> Inspection Form Included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspe�'sftature hone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Corr correct: X V" L E' I ; 2 3� <br /> I White Copy: IV✓ Yellow Copy:Operator Pink Copy:LEA <br />