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_= Waste Tire Su46y & Inspection Reporteinspection Report Number <br /> StatofCalifornia <br /> 62M ew 04/04) <br /> Califollntegrat d WasCWB 181 tle Management Board Survey Form - Page 1 Il - 1088377 <br /> Part A- Surveys BLUE OR BLACK INK PEN <br /> Business Profile : nspection Details <br /> - - - - - <br /> TPID- L] Inspection Type (Fill one) <br /> Site Suffix: I IT� I <br /> ' I `� 17 I L� I U tC) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: k �,�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> it <br /> Physical Address VI - f <br /> / <br /> . ? <br /> Streer i �h ___'A <br /> _ �, Inspection Date (. ) (� <br /> 7 � �� -) y <br /> rI <br /> State ZIP Code Time a In Time Out <br /> Business Rep Title 0 AM / ! 0 AM <br /> L-' <br /> 0 PM O- f ! 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/ E) L� /1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / v ®Active Q Passenger 0 Generator 0 Outdoor <br /> ' O 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that appl <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 A HAULING AND MANIFEST REQUIREMENTS <br /> 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 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: <br /> Comments Included: <br /> �s-Rep's Signature Phone Number Inspector s Signature Phone Number <br /> _. <br /> T NI F L E <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: /X � E :K A 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />