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Waste Tire Sul, - %,pAy & Inspection Report ..tspection Report Number ■ <br /> =908 �WMBCalifornia <br /> 11(New04/04) Surve Form - Pa�uye 1 I1 - 1144001 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile i Inspection Details <br /> TPID- + ,^ O I Inspection Type (Fill one) <br /> Site Suffix: ( v I ! 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local1 t n If Referral,choose referral type(Fill one) <br /> Identifier: Sao J-Q(,l�'j Ltl \ `, fl+ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 (, Inspected By Inspector <br /> Physic AdDdress l��l m2 tli �✓j P, � O &CAo <br /> g3o1 IVcw}on -- <br /> ICUDS <br /> Inspection Date , 3 0 <br /> O CYL'r D n <br /> Time In Time Out <br /> Business <br /> sCO Rep Title - <br /> C _ } Q : 5 J <br /> AM <br /> � ® AM <br /> CSoP Ft)rm&(, QPM O PM <br /> Operational <br /> Status Tire Type i Business Role Storage Type <br /> Tire Count(Whole/PTE) 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / Q Active 0 Passenger 0 Generator 0 Outdoor <br /> D • Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 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 ®OtherEn+ D-L, <br /> (,f- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> V q 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 01 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 1 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 EXE <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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments PcAorrngA <br /> J <br /> oc0 ��us <br /> Inspection Form Included: S <br /> p Oi wk&- `Z9'3�33.2 - C. <br /> Comments Included: <br /> �L�� 'J <br /> usiness Rep's Signature Phone Number Inspe or ignatur Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect:Iorrt r X X , p i T 62081 <br /> _ "!' - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: ® ■ <br />