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Waste Tire Su@ey & Inspection Report Inspection Report Number <br /> .•�ql State of CaliforniaCIWMB 181 0-4/04) <br /> J <br /> California Integrated Was eeManagement Board Survey Form - Page 1 ! 1 - 1 1 3 5 5 2 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 1 ,� l ; E (D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> r- -� <br /> Physical Address <br /> ) 5�) VV , G(od Loll_, L <br /> Street <br /> f CA � .,- (_//i �_, ` 30 <br /> Inspection Date - / LTJ / <br /> f -' 1 <br /> Citv State ZIP Code Time In m TimeOut <br /> Business Rep Title L I�_l O AM O AM <br /> O PM O PM <br /> Operational Status ire Type Business Role Storage Type <br /> (Fill one only) Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PT J <br /> Active Passenger 0 Generator 0 Outdoor <br /> O 0 Closed Altere <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 inactive Tru <br /> Longitude — 0 Planned 0 OTR 0 End-Use Container <br /> Business Type (Fill all that ap <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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V i 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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 0 114 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments J <br /> T�1` L �( •_ t`(� � �U�� lt ( �„ (}l i� � i'•_Nt Y� (� .��, 1v1t �iij�-1 - <br /> i >� <br /> "i;f'=- rf i� 11a`t r �1t), , i t�_i t.M• �� �(_'If�l 4") — <br /> tl'i 3hr �_� LUi)h fi(;'a, lr:tlr �Cl J� ti (`UI ✓tYv;� (A ' � <br /> /OA, ��iU.wilL)C (t`t +it, ( nI t� <br /> Inspection Form Included: <br /> Comments Included: 0 Business Rep's Signature Phone Number Ins ector's Si nature P <br /> p' g p _ g : _ hone Number <br /> h2I,i: 1 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A�, E X I A rdl I P I L 1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />