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Inspection ection Re ort Number y & Inspection Repor Waste Tire S _ <br /> State of California -_ <br /> P , fj� I <br /> Part Aew 04/04) <br /> Calsu not ghat dClWMB 1 Was81 te Management Board Survey Form - Page 1 1 L BLUE 0 1 3 5 6I K <br /> yl PEN <br /> Business Profile "'4. "; Inspection Details <br /> TPID- I � f �f Inspection Type (Fill one) I { <br /> Site Suffix: ' CJ ] �^ �J / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ' <br /> CD(AKI <br /> If Referral,choose referral type(Fill one) <br /> Identifier: 1`1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l - I <br /> l J 11 Yt 1. (.c•c�- <br /> VJ Lie, <br /> Street <br /> Inspection DateF-0 DEC <br /> /_rI 7 �(-t l / lel <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> [1] . O PM O PM <br /> Wtic r <br /> Operational StatusBusiness Role Storage Type <br /> (Fill one only) ( (Fill all that apply) (Fill all that apply) <br /> Active ( Generator 0 Outdoor <br /> GPS Latitude O . 0 Closed 0 AI t + <br /> � w, ��r, <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Tr <br /> uek <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> New Tire Dealer I!" 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 1 HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 (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 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 1 0 Other: § <br /> Comments Acr�•i.��+j <br /> c- <br /> jk- <br /> Inspection Form Included: 0, <br /> Comments Included: 0 <br /> - -- - -- - <br /> Business RepPhone Number's Signature Inspector's Signature Phone Number <br /> - _ <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: 62081 <br /> �/ �, 1 . L ; <br /> ■ White Copy:CIWMB Yellow-Copy:Operator Pink Copy:LEA `—iJ ® ■ <br />