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°__ <br /> Waste Tire RRey & Inspection Rep" Inspection Report Number <br /> A <br /> State B 81'fornia <br /> (New 04/04) SurveyForm - Page 1 Il 1140795 <br /> California Integrated Waste Management Board <br /> Part A-_Survey __-- __ - _ BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> TPID- ` � O d � � � - O 1� - Inspection TypeO(Fill one) O O <br /> Site Suffix: I 1 Routine Re-inspection Referral Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier- J fan��n C �,`�Ti/� — 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name I_ I J Inspected By Inspector <br /> �JsNL�e S V T1 no _ //^� <br /> Physical Address 1 V I �C� ESuU <br /> C � 15au� Inspection Date 1 1 � a C1 � 1 <br /> Time In Time Out <br /> Business Rep,� TitleO AM C 0 AM <br /> 1 �O�t�rRnO 1� ►e-I.�f1rA[Q,� uL(}/�.Qf` � � v SPM � S v (1111111 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 /> Active 0 Passenger ® Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude O Hauler ® Indoor <br /> t7 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> I <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ® 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A HAULING AND MANIFEST REQUIREMENTS 0 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 /> 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 EXT) <br /> 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 In Compliance No Violations <br /> 0 0 Other': §� <br /> Comments L 1�T d <br /> --- --- For - <br /> PJ <br /> Inspection Form Included: 0 <br /> Comments Included: - - <br /> ®'B iness Rep's Signature Phone Number Inspec is Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: incorrect: <br /> 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ® ■ <br />