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Waste Tire Sur . _.1 cx Inspection Report osN._.;tion Report Number ■ <br /> CIWMB 81'fornia(New 04/04) Survey Form - Page 1 I 1 - 1143555 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ��^^ Q Inspection Type (Fill one) <br /> Site Suffix: $ l V I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local t ` If Referral,choose referral type(Fill one) <br /> Identifier: S(�f1 �OU�lllf� C(9t�1� lJ� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By `` Inspector <br /> Qs ik'm Tr u t,YLi n� •1�G. 9 - I <br /> Physical Address j O ( 'Jen ES66 <br /> UU..b <br /> C A Inspection Date S 0 5 I V d etc ot, gsa�s <br /> Time In Time Out <br /> Business Rep Title 1 I AM ` ® AM <br /> OO PM L ' 50 0 PM <br /> Operational l Status ( , ( PP Y)_— - - <br /> —--- -- - - - - p The Type Business Role Storage Type <br /> Fill one only) Fill all that apply)! Fill all that a I (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> ® Active Q Passenger ® Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive I ® 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 • 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 <br /> m / 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 O _ --- <br /> 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/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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments WIN. 11`15 ' ,"�v�1 CX�� IPTG_-Ol_fl(/�-_�►'U�(�������_��� <br /> e1�o\4iW.n___V_tJW9- <br /> Inspection Form Included: Q J �Signture�Comments Included: ® �0 ?WRL,Busine ep's ignature Phone Number Inpec Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect i 62081 <br /> � 6 L ', Sid 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink WA ■ <br />