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Waste Tire e & Inspection Re � Inspection Report Number <br /> i jN <br /> A�� State of California Y <br /> CWMB <br /> 1(New04/04) Survey Form - Page 1 11 - 1127605 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- `� �� 10 1l1li <br /> Inspection Type (Fill one) <br /> 1 <br /> Site Suffix: ' E 6' , t 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> r� <br /> Local (7, If Referral,choose referral type(Fill one) <br /> Identifier: �� , u �� I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �I <br /> Physical Address <br /> ._. <br /> u._.?.._......._Laa ...: ........__..._....�_'�._(-�,f_.._........... ........_............._ <br /> Street, ._..._._......_...........Street, Inspection Date Ij I I / <br /> F, M <br /> stat r d Time In Time Out <br /> �,=r,e 2tF'w�<}t��: <br /> Business Rep Title ' j f O AM 1 O AM <br /> I I(v} I .' O PM O <br /> t� P M <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 1 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned OTR End Use ( Container <br /> Business Type (Fill all that apply) <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 /> 0 0 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 A(ItV— <br /> t j kc <br /> Inspection Form Included:0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E- . A MMP, ( j . I <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />