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J Waste Tire S*y & Inspection Repor Inspection Report Number <br /> kaState of California <br /> rCIWMB 18a(t(New04/04) Survey Form - Page 1 Il - 1127743 <br /> California Integrated Waste Management Board Y <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ® Inspection Type (Fill one) <br /> Site Suffix: ,�, 3 i .® Routine Q Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 Ulf �o6t jL j n - � Q CHP O CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address n jo <br /> CA I S,-qS Inspection Date 1 � � 0 <br /> 117 0 <br /> Time In Time Out <br /> BusinessRepTitle i � 5 C) 10 AM S AM <br /> QPM � F � � QPM <br /> (044 <br /> - -- -- - - - Operational Status Tire Type Business Role I Storage Type <br /> Tire Count (Whole/PTE) `7 (Fill one only) (Fill all that apply) (Fill all that apply) I (Fill all that apply) <br /> 6 Active Q Passenger 4) Generator e Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O O Inactive *Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer. Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ---- ----- --- <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m m <br /> 010 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> I <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 46 In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> 1 J <br /> �o v,a�►o�5.OsGQ.Sclt,S --C-��n � -- - <br /> ,Inspection FormInclude : <br /> Comments Included: -"'��`` � � <br /> - --- -- - - <br /> j Business Rep's Signature - -_Phone Number In pe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect } w'� X 1 1 2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LE ® .. <br />